So on to tonight's webinar, it is free access thanks to the very kind sponsorship of Fiorina, as I mentioned. We're delighted to have Mars Chandler with us, speaking tonight, who's a clinical nutritionist at Vets Now referrals in Glasgow, a private consultant in small animal medicine and nutrition. Before we hand over to Marge, Libby Sheridan from Purina's on the line and she's just gonna say a few words about the series.
Thanks very much, Paul. So thanks everybody for joining us this evening and thank you to Marge for helping her, helping us with her insights on this topic. I think diarrhoea is something that remains challenging in practise.
And certainly things have moved on quite a bit since I qualified many moons ago with investigation, but I think we can still struggle with knowing how to nutritionally manage these cases and what approach is best for the individual patient. So it's wonderful tonight to have somebody so experienced and knowledgeable as Marge and Presenting on this subject tonight and as Paul said, Marge is both board certified in nutrition and small animal medicine. So that kind of gives her some really good insights to share with us.
So I'm very much looking forward to it and I hope you enjoy it too. So I'll hand you back over then to March. Good evening everybody.
Thank you so much for giving up your evening to, to spend with us talking about, talking about diarrhoea. I just thought you'd probably just all after dinner with a glass of wine. So, great topic to have for that.
Fortunately, vets cope well with this, don't always. So, yeah, this is a, a, a passion of mine, both the gas as a gastroenterologist and as a nutritionist, so this combines a couple of things well for me. .
Nutrition is absolutely the main treatment for many gastrointestinal disorders and it's an adjunct for many others. I'd almost say nearly all others. And really it's an adjunct treatment for every single patient that you see, isn't it?
Because there, you need to feed them all and often nutrition is a vital part of what we're treating with disorders. So what I wanna start with is just to, to remind you that a nutrition nutritional assessment, including a diet history is important for every case that you see. I still get cases referred to me where I can't tell what they've been fed.
It's really, really imperative for GI diseases. I'll go through a case later this evening. Hopefully, we have time to do to me.
And I'll talk a little bit about how this fits in and how important it was in this case. So, nutritional assessment, you fit this right in with your regular history and physical exam. The minimum for that is a diet history, which I'll go into a little bit more detail in just a second.
Body condition score, I like the was saw a body condition score that I have the kitty one in the corner there, so 5 pictures, but 9 descriptors of that, it breaks it down quite nicely. So 5 is normal for cats, 4 or 5 for dogs. We also add a muscle of mass evaluation to that because, especially in cats, but sometimes in some other protein losing disorders, you can get retention of body fat but a loss.
Muscle mass, which makes it very hard to assess the body condition score without adding that on. So diet history, what are we looking for? OK, what exactly is fed?
That sounds very simple. It's not always what the answer that we get is. So it would be great to know how many times a day the animal is fed.
Where might be important. I have to admit I don't always ask that question. Sometimes it is important, especially if there's competition with other animals.
When is it fed? That can be very important and we will touch on that in a little bit. Treats and snacks, and I'm gonna give you just your, a, a quick tip on this, that a friend taught me is do not ask the owner if they Feed, treats, and snacks.
Ask them what treats and snacks they feed. Some owners are kind of self-conscious and think that they shouldn't be doing this. This gives them permission to give us the information that we must have.
Otherwise, you may not get this information and it can get quite difficult to put a dog or a cat on elimination diet. Dental chews, a fair amount of calories in those. They can throw off, if you, a diet, if you're trying to kind of keep track of exactly what an animal is fed, this is sometimes not perceived as a treat, so the owner may not mention it if you don't ask.
And embarrassingly, I got caught out on that just about a week and a half ago. I forgot to ask that question, so it's something we all need to kinda keep thinking about. Food for medications.
Again, it's not a treat, is it? So the dog or maybe even a cat who's getting a non-steroidal for arthritis or something or heart disease or something. It's not a treat.
This is something that the owner will associate with the medication rather than being a food. What do we use in Britain? Cheese seems to always come up as the number one, for a healthy animal that might be OK for a dog or a cat on a restricted diet.
You might wanna think about if that is the ideal way to be doing this. Capsules used for medication, they are made of gelatin. They're going to be either bovine or porcine, so either cow or pig gelatin.
Probably it'll be OK in most cases, but if you have an animal that's extremely sensitive to either bovine or a porcine antigen, you need to know about these. You might need to cut those out. So consider using a diet history form at reception so that the owners can fill out all of this information kind of in their, in, in their own time while they're waiting for their appointment.
And if you don't have a guidet history sheet, there is one on the Masava.org nutrition tool kit along with the body condition scores and muscle evaluation and everything you need to know about doing nutritional assessments. I'll just leave that up for a second in case anybody needed to write that down, although I think you'll have access to these later.
If you go on to Osava.org, you can look around and you'll find the nutrition tool kit. If anybody has used that in the last year and struggled with it, my apologies, it's taken us a year after they improved the website to sort this out, but I think we have it sorted out now.
OK, what a diet history is not fed dry food. You see this all the time, this is considered fed canned food, it's fed dry food. The history should be exact enough that if you hospitalise this animal, you could feed them the way they're being fed at home and you can't do that with this minimal information.
One I love and I I I think I see this more for GI disease than anything else that I deal with it. The owner has tried feeding everything when you ask them, what have you, what have you fed. I have fed everything.
I'm sure you've all heard this. OK, about 200 new foods come out every year. They haven't tried feeding everything.
Very anecdotally, in my experience, when they've tried feeding everything, it's about 3 to 5 different foods. So they really haven't. So you need to get a better idea, especially for the GI cases, what they've really fed.
And here's a classic, what is your pet's diet and there's nothing filled in. So you cannot work up a GI case with this on the history. We need to have more information.
OK, so why do we need it? What does the diet do with the gastrointestinal tract? It affects GI motility, it affects cell renewal.
The microbiome, which, most of you will now know that as the microbiota or the microbiome, that is the bacterial flora and its environment and it's DNA and everything around that. So that is a big area of research that we're finding out more about almost daily. Enzyme production in the belly, the ammonia production, the free fatty acid content, it affects the immune system.
And the diet can also contain things that have a negative effect toxins, allergens which cause a food hypersensitivity or true food allergy, or a food intolerance, which is a food sensitivity that's not actually immune-based, but still can cause the same sorts of problems. Unbalanced diets, excesses, deficiencies, these can have an effect on the, on the animal overall or a direct effect on the GI tract as well. So, I'm gonna give you just a very brief outline.
I'll go into detail and more of this, but if you need to take a nap later or can't stick around, this is kind of the crux of the first part of what I'm going to talk about is the different kinds of diets that we use for GI disease. So the first category, and these are pretty much how these are marketed, there's a little bit of variation here and there between different brands and different products, a highly digestible diet. These are useful for acute gastrointestinal disorders for late feline megacolon.
So when it's truly a megacolon and the cat really doesn't have much motility left, sometimes for chronic enteropathies, but I'll talk lots about chronic enteropathies in a bit. Novel protein diets, again, for enteropathies or colitis, the chronic neuropathy or chronic colitis, they have a potential place there. Hydrolyzed diets, again, enteropathy or colitis.
I'll talk a little bit about how I choose between those in a bit. Low fat diets, for lymphaictasia, for pancreatitis. Increased fibre diets, which might be part of a low-fat diet, they might be something slightly different.
So I'd like you to think of those two things separately. These are useful in colonic disorders, including constipation. Including the early feline megacolon constipation cats, and homemade diets.
These can be useful cause they can be tailored to the pet and the pet's disorder, especially if there's more than one disorder present. So that choosing another diet, so it works for something, but it doesn't work for something else. Sometimes a homemade diet can be useful.
I, even though I formulate homemade diets, I actually prefer the commercial diets because of the research and development that go into them because the test. The thing that goes into them and because of the quality control, homemade diets just cannot duplicate that. Then I'll mention that again.
So, highly digestible diets can also be thought of as low residue diets, so they're going to be low fibre diets, so that's what makes them highly digestible. They're usually lactose and gluten-free. Do we need to worry about that?
Gluten intolerance pretty uncommon in dogs and cats, even though owners think it's common. Documenting that, it's probably not that common. Lactose, yeah, they don't always have lactase around it.
It's probably a good idea that they're low on that. They're usually a low to moderate fat content, but these are not necessarily the low fat diets that you might need to choose in some cases. They may contain medium chain fatty acids which potentially could be beneficial in some cases.
Some of these have increased antioxidants, increased N3 or omega-3 fatty acids. They may have prebiotics which Actually would add a little bit to the residue, so maybe not too much of that. Now, the one thing you need to remember about some of these is they may contain multiple protein sources.
So you, if you're looking for an exclusion diet, sometimes these are not the right diets as an exclusion diet. If you're looking for a diet that is different from what the animal has had before, some These can have 3 or 4 different protein sources. So, depending on what you're looking for in the diet, this may or may not be the diet that you choose.
It may be highly digestible diets are very useful, for, again, acute gastritis enteritis, for pancreatitis, possibly depending on the fat content of that diet. And also for the later stages again of feline megacolon when the motility is pretty well gone. The cat can't really move a diet very well through the bowel, unless it's quite low in fibre and low residue.
OK, Novoprotein or limited ingredient diets. These can be useful for suspected dietary sensitivity either to diagnosis or diagnose it or treat it. So, I hate the word hypoallergenic on some of the over the counter products because it means absolutely nothing.
I have seen a diet with intact protein chicken. For cats, marketed as hypoallergenic, there's no legal control of this term. Anybody can call anything they want hypoallergenic.
For the majority of cats, chicken is not a novel protein, so it's not hypoallergenic unless that happens to be a cat, which has never had that protein. When I lived in the States, we often used lamb as a novel protein diet. And then I moved to New Zealand where everything had been fed lamb, so it really, really depends on the individual.
So it should be a protein and probably a carbohydrate source that that particular pet has not been fed previously. I had an internist last week when I told him that I'd made up a beef-based diet for a dog. He said, Well, that's not a novel protein.
I said, yeah, for that dog, it is. He's only had chicken and fish. So, even, and this is a well-known internist, so it's easy for people to misunderstand this.
OK. Again, you need a good diet history. All the things I mentioned, treats, snacks, foods for meds, gelatin capsules.
We really need to know what proteins they've been exposed to previously. So you're gonna do homemade or commercial. We've got some pretty good all the protein limited ingredient diets that are commercial.
I Sometimes do these as homemade diets. I often get people who request that, . The commercial diets, if they are a therapeutic diet made by a reputable company, they're probably OK.
Some of the smaller companies, the over the counter products, have been shown to frequently be contaminated with other protein sources because in order to develop one of these, to, to produce one of these, excuse me, you need to really, really clean your factory out and I think some of these people aren't able to control. Contamination from, say, beef into a fish diet or whatever. So, I would go, if I had my preference and I wanted to use one of these, I would go with one of the bigger companies that does good testing that I trust what they're doing when they do it.
I am also happy to make a homemade diets if that's what we end up doing with this. So for, if you're looking for dietary sensitivity, if you are doing dermatology, this, if you think about the turnover time for the skin, it probably takes 6 to 8 weeks. Some of the dermatologists will go out 10 to 12 weeks before they say yes or no.
Does the animal respond to a limited androgen diet? For GI we're lucky, most respond within 1 to 2 weeks, and that's about 2 weeks is about what most gastroenterologists will recommend. And even then, you've probably all seen this to where you change the diet and they're, they're better like in 3 or 4 days.
So it's a really, can be a really rewarding thing. Next, I wanna talk about hydrolyzed protein. Apologies to slight is ever so slightly blurry.
I tried to get a cleaner version and I couldn't, but it's a nice description of how the proteins are cleaved or broken up by enzymes and acid into smaller peptide or amino acid fragments. So that's literally breaking the protein down into these smaller bits. And what we're looking for.
Is peptides of 6 to 15 kilotons, at least under 20 kilotons, and most of them are lower than that. The products that we have so far are made up of either soy proteins, hydrolyzed chicken, or feathers. And the particle size in theory should be too small to be antigenic so that say IgE can't link to two IgEs can't link to the protein and, and cause a mass cell reaction, and that it just doesn't.
Once in a while, you still can get an antigentic response to an epitope on the peptide. So if you have an animal that's you feel is sensitive to chicken, can you use a hydrolyzed chicken diet? Probably, although certainly the dermatologist and I have had some GI cases as well, it, it might be better to cho choose something different.
So maybe go for soy instead. So try to choose a different protein, even though it shouldn't be antigenic cause it's too small, I would advise going for a different one. These again, excellent for elimination diets and treatment of foods and.
They are, and I'll mention this again, effective as a treatment in about 2/3 of the chronic neuropathy cases. Let me go back just a second. And the question always comes up, somebody may have already written this down.
Do I wanna use a novel protein or do I wanna use a hydrolyzed? I will usually start and this is Partly anecdotal, partly evidence-based, so partly it's just me saying this is my experience. Partly there is a study on this.
I start with hydrolyzed. I've had such good luck with the hydrolyzed diets and GI cases. And there was a study looking at hydrolyzed versus novel protein, and 2/3 of the cases responded to either one, novel protein or hydrolyzed diet, good initial response.
3 years down the line, more of those, it was a dog study. More of those dogs were still in remission. Who went on to a hydrolyzed diet.
So I try to start with those and I will usually stay with them, especially in, in the severe cases. And usually, most of my owners don't want to switch. By the time they're, especially the, the dogs and cats I've seen.
By the time the diarrhoea stops, the owners really wanna continue with that, and I'll talk about that later too, I hope. So low fat diets, the low fat diets that have been developed for us by the commercial companies have been just fantastic. So we're talking about A diet that is less than 20% fat on a metabolizable energy basis.
Dry matters a little bit harder to check on this, but the three big companies all have good low-fat diets, so I would go to those for pancreatitis, canine pancreatitis certainly. Feeling we know less about. Canine pancreatitis, some people feel like if the diet is lower in fat than the dog was on before, that might be good enough, but since we have such great commercial low fat diets.
I actually certainly would start my treatment on one of the commercial low fat diets. Yeah, you can do a homemade one too, but we've got the commercial diets here. For hyperlipidemia, say your schnauzers that, that have high triglycerides, yup, low fat diets.
And another one is lymphaectasis. So this is one of the types of a chronic neuropathy that I would go low fat over novel protein or hydrolyzed. I would go to the very low fat diet if you have it.
Definitive protein losing and neuropathy with dilated lactals that are losing lymph into the intestine, low fat diets, there's been a couple studies now showing the best chance of remission is with these diets rather than hydrolyzed. You might need to add red, you might need to add other drugs to that, but if you don't get the diet right, you're not going to get a good treatment response. So remember, some of the low fat diets are high in fibre.
You need to decide is that the right choice for the pet that you're looking at. Say, your protein losing and neuropathy dogs might be quite thin. You don't really want a high fibre diet because it's gonna be lower in calories.
Some of the high fibre diets on a metabolizable energy basis will actually be a little higher in the amount of calories that are supplied by fat. So again, I would look for a low fat diet that's designed pretty much just to be a low fat diet, not a, not a high fibre weight loss diet. So have a think about which ones to choose when, when you are using, especially for pancreatitis and lymphatic.
So high fibre diets, we'll go kind of the flip side of that. I can talk all night about fibre on this because there's really so much to it and I think the way that we talk about fibre is often overly simplistic. It's a good starting point to talk about soluble versus insoluble, but there's lots of other properties of fibre that make even this approach a little too simple.
So there's how fermentable they are, how gelling they are. So, soluble is pretty much how soluble it is in water. So this is a good starting point to talk about some of the ones that break down in water and the ones that don't cause they have completely different effects on the intestine.
Soluble fibres can slow down, GI motility and soluble don't. So some of the potential benefits, fibre is low in calories. You figure proteins and proteins and carbs are around roughly 3.5 to 4 calories per gramme, fats around 8 or 8.5.
9 fibres around 1.5 to 2. So the more fibre you have on a diet, the lower the total calories per gramme of diet.
So good for weight loss, weight control in dogs, probably helps with some satiety cause you kinda like eating a bunch of salad before you have your dinner. It kind of fills up your guts a bit. The fermentability, is quite positive, for some cases.
So for colonic disorders where you can get some fermentation and short chain fatty acid production such as butyrate, this will, Feed, feed the colonocytes themselves. The klonocytes like butyrate as an energy source. It can also say soften the stools as well if you need that, if you have a constipated animal too.
So, that's the soluble fibres, the insoluble fibres, which aren't water-soluble, they're generally less fermentable. They're things like cellulose. They will bulk out the faeces.
They can help some animals defecate just because the faeces are a bit bulk bulk bulk bulkier and will stretch the colon a little bit and stimulate defecation from that. If you are feeding or switching a pet to a with a lot of insoluble fibre in it, you do need to warn the owner that the amount of poo will increase. And some of the, some of the diets that contain considerable fibre, sometimes the poo increases quite a bit.
That can make a big difference in a big dog. The soluble fibres, again, the jelling fibres, the fermentable fibres may increase flatulence if you get a whole bunch of soluble fibres, especially in an animal that's not adapted to it, it can actually soften the stool too much and you can get di. OK, I wanna mention a little bit about high fibre diets and cats.
Well, it works well in dogs to have high fibre, you can get high fibre weight loss diets for cats and they do seem to help. There's been some studies looking at all sorts of different versions of this, but The best thing seems to be maybe moderate rather than high fibre and a high protein and low fat diet seems to be the best for cats, high protein in dogs too. So where we do look for highly soluble fibres is feline constipation.
Even if you're seeing it, say, with something like hypercalcemic, idiopathic hypercalcemia can cause constipation in cats, and I've had really good luck adding something like psyllium to a diet or using a diet that has, soluble fibre in it to just soften the stool so that these cats are more comfortable defecating. Pelliium is the same thing as espagola, by the way, the same exact plant. OK, again, cats with, by the time their colonic mortility is poor, we're going low residue, low fibre toward the end.
So, a few other things that are sometimes added to GI diets, vitamins E and C as antioxidants, of course, most of our dogs and cats don't need vitamin C because they already synthesise it in the liver, unlike us, in some cases, some added bits might be beneficial. We have fish oils added to some omega 3 fatty acids or N3 fatty acids. They're the same thing.
They decrease inflammation and provide for less inflammatory cytokines that might have some benefits in some cases. Glutamine is amino acid that provides energy to the small intestines, so some of that, those may have that added lycopenes again as antioxidants, beta carotenes as an antioxidants. Now, We don't have specific studies in feline or canine GI disease and especially we don't have the studies for individual antioxidants.
They're often done as a cocktail, like several different things added together. . And they're, you know, they seem to have a benefit in some cases when they're added as a cocktail, but we don't, we can't really tease out, oh, this specific thing is doing this.
You don't want to just add a bunch of vitamin C to a dog's diet. Otherwise, or a cat, some of these can become pro-oxidants in high amounts if they're added individually. So it is a A bit of, a bit of high science that goes into deciding what to use and what amounts to use and how to combine these.
So it's nothing that I would really add to a homemade diet other than the fish oils, which I do, and I quite like the fish oils added to a lot of these diets. Not if it's an exclusion diet, so just if it's overall. OK, just wanna mention briefly vitamin B12 orcabalamine.
Which is often deficient in GI cases, also in cats with pancreatitis and protein lying neuropathies. it's quite easy to get too low in cabalamine even though the liver makes some itself. Important in GI cell repair, the gas the gastrointestinal tract won't repair itself if it's deficient and so many of these are.
So dose is kind of arbitrary 250 to 500mg subQ if you're doing parenteral about once a week or every two weeks. And I will tell you this dose was created very arbitrarily because as you probably know, 250 ms is a quarter of a mL and that that dose was chosen because they figured it was easy to see. And it will repeat both cases to do that.
So, roughly, you do this every week for a month or two and then go every 2 to 4 weeks, whatever works in that pit to keep them up. We now know that there is the oral sycabalamine. I have cobalaquin down here, Cabalaplex is the one that most of us have available.
We now know the oral does work in GI cases. There was a lot of scepticism about this. A brilliant Swedish researcher working with, some people in Finland did some fantastic work on this, Doctor Linda Soren Torres and, and has proven that even in cases of chronic neuropathy, oral cabalamine is absorbed.
So you can sometimes start them off in parenteral and then send the owner home, to give them orally as long as the animal's eating well. Some of these cases, you might also need to supplement folate, but it's, it's not too common. If you do have a low folate, you can certainly, you can buy that over the counter and, and supplement that as well.
I wanna just mention briefly a little bit about prebiotics. These are sort of a fibre source to Kind of, if you wanna use the advertising version of this, feed the good bacteria. So these are meant to be providing energy for the beneficial bacteria to ferment, and we have things like fructoligosaccharide that's added to some of the pet foods.
Me and Legosaccharide is as well resistant starches, which are kind of a whole. Interesting category of sort of fiber-like products and rabino galactans as well. You will see these sometimes added to products and you can also buy them separate.
So these are kind of like fermentable forms of fibre, but they're sort of prebiotics fit into their own category. They produce the short chain fatty acids, including butyrate which again provides energy to colonocytes, so probably have some benefit for some cases of colitis. Again, they promote the growth of the beneficial gastrointestinal bacteria, the microbiome, such as the phytobacteria and lactobacilli, and there are lots of different types of those.
So hopefully, we're promoting the good ones when we use these. They are meant to suppress pathogenic bacteria such as salmonella, some of the E. Coli is, Campylobacter.
There's been some efficacy for diarrhoea. It's usually not my first choice, although, if I had a product that already had it included, I would consider that. I don't ever add these to a diet because we wouldn't really know how much to add.
So this is more of a look for these to be included in some of the diets if that's what you're looking for, especially for perhaps a colitis. I can, this is labelled they may be in the food, soluble fibres, kind of similar thing. And it just mentioned probiotics briefly.
This is kind of an overwhelming topic. I can actually do over an hour lecture talking about nothing but this and then even barely touch it. So, live microbial agents, probably generally live.
Someone, in some cases, the DNA from the dead ones might work too. Nonpathogenic food grade species, possibly from the target species or not. A lot of them are not.
Some of the ones that we know generally, the big classes have some bene benefits or the yobacterium, some of the Lactobacillus, there's a whole bunch of different types of lacobacilli, inococcus specum. There are some general effects that most probiotics have. There's more specific effects that we need to narrow it down to picking a bug.
We might even need to pick a strain of a bacteria because For instance, not all Lactobacillus, acidophilus are created equal. There's different strains. So some of the things that we know that they potentially can do is compete with pathogenic bacteria, is decrease bacterial translocation, and some of them, not a general effect, but some of them can stimulate the immune system.
I'm not really sure if that's a good thing or a bad thing though. Sometimes it seems like that might not be a good thing. I do wanna mention Fortiflora, which probably has had, as much if not more research, on it, of any of the commercial products that we have has shown some benefit in acute diarrhoea and stress-related diarrhoea such as sled dogs who have a tendency to get diarrhoea.
Kennel dogs, it's been shown to have a benefit in the stress, the diarrhoea related to the stress of being kenneled that some dogs. Can get. It works probably better.
So, if you know you have a client whose dog gets diarrhoea when they are boarded or something, probably works better to start this before they are kenneled, so prevent rather than try to catch up and treat later. For the acute diarrhoea, the stress-related diarrhoea, they will shorten, it will excuse me, shorten the duration of diarrhoea, but again, if you know they're going into a stressful situation, it might be better to do it ahead of time. So, the probiotics work?
This is kind of my ultimate slide. I gave a talk at BSAVA on this probably 10 years ago, and my first slide said I don't know. And my last slide also said I don't know.
So we do know a little bit more about that now. We know that some of them work in certain conditions, but They're not the same thing. So we have lots of different potential bacteria and cocktails of bacteria and sacromys is a yeast to sometimes put in there as well.
What we need to look for when you are choosing a probiotic. Has this probiotic been used in this species, in this type of dog or not type of dog, but in a dog or in a cat rather than a human for the disorder that I am treating? Has it been used for acute gastroenteritis in a dog?
And then, yes, then choose that. You know, we can't really say, do they work? There's no yes or no to that.
Answer. It would be like saying the antibiotics work. Well, if you choose the right antibiotic for the right disease, yes, it does.
And if we can know what probiotic to choose for what disease, they probably will. Right now, in spite of there being quite a few years of research on this, we still can't always answer this question. We still don't always know which one to choose when.
The over the counter ones not so likely to work, so I would look for ones that have research behind them. OK, I'm gonna talk about just in general, kind of acute and chronic GI cases and then hopefully I'm gonna have time to go through a case that will illustrate some of what we're talking about. So, dietary indiscretion is the best ever sort of name for what we really mean is got into the rubbish.
So it's sort of our tactical way of saying, saying your dog misbehaved. Usually dogs, like, we do see some cats that misbehave, but I think This might be a prejudice. I mind, but I think it's more often dogs that do this than than cats.
Certainly some of the cats do as well. So what can go wrong? Bacterial toxins and spoiled food where you can directly cause vomiting and diarrhoea, basically food poisoning.
We all know that specific toxins in some foods can cause problems. Or if it's an excess or a rich food, say, a highly fatty food that the animal is not used to, it sort of has the effect of a really rapid diet change to a food that the animal isn't used to. The food may not be absorbed.
So that water is drawn osmotically into the gastrointestinal tract and you get the diarrhoea from that. And certainly we see this pretty often when they, you know, they get up and get into the Christmas dinner or something when you're not watching and polish it off. We do know that adult dogs and cats are often lactose intolerant because they no longer have the lactase they had when they were growing up.
So if they get into a dairy product, including yoghurt, by the way. Diarrhoea from not absorbing the sugar and again it's an osmotic diarrhoea, the water is drawn in and the sugar has stayed in the GI tract because there's not enough lactase just it. So, possibly, like I was a long time ago, the treatment for this, we used to all just recite this, didn't we?
Some of the younger people won't, fortunately, I hope, withhold food for 24 hours. OK, this is something I was taught in that school and I, I still hear people say this too. You know what that was based on?
That was based on absolutely nothing. We kind of made it up. This idea of bowel rest is a fiction.
The bowel. Keeps doing things when there's no food in it, you know yourself that your bowel keeps doing things when you're hungry cause that's why your stomach gurgles. It's, it's sort of, you've got peristalsis going on there.
So you don't really rest the bowel, you mostly upset it by starving it. So yeah, if you have an animal with absolutely intractable vomiting, and we have all had this at some point ourselves, you, you don't want to eat, it's not even a consideration. But short of that, I do not withhold food.
You probably don't. If you got just a little sick to your stomach but felt OK tomorrow morning, you're not gonna starve yourself until tomorrow night. That would not be healthy.
The gut needs nutrients. So, number one is always to hydrate the animal. Parental parenteral fluids if needed, and by the time they're showing any signs of dehydration, parenteral fluids are needed.
So hydration is number one. Probably electrolytes, particularly potassium and then possibly sodium, would be the next thing you wanna make sure that they're not deficient in because the gut's not gonna work if you're hypokalemia. Anti-emetics, so.
My favourite is Marropotent now that we have that. It's a brilliant anti-emetic. It doesn't cause problems with obstructions, but it can mask an obstruction because it's such a great anti-emetic.
So if there's any chance of an obstruction, rule that out, and then I would go with. And a highly digestible diet is what we're gonna treat this with. Please don't say a bland diet.
So it was always, we used to be told, don't feed and then feed a bland diet. There is no such thing. Dog food is bland.
Cat food is bland. There's no Mexican dog food. There's no Thai dog food.
It is bland. That's not what we should be saying. It's a highly digestible diet.
So some of those at this Point, it probably doesn't matter if there's a mixed protein source in there. This is the place for those highly digestible diets with some of the antioxidants, and some of the other things added. So we want to have something that the gut deals with easily, but bland is not the right term.
So, the other thing that was often done, I think as a profession, we're getting smarter about this, is not giving antibiotics every time something walks in the door. Antibiotics are not indicated unless you're pretty sure that there's a bacterial toxin going on. So you're just gonna cause more resistance if you give these when they're not needed.
OK, and I wanna talk more about chronic neuropathies. These are the ones that I often see because by the time they're not responding, that's when they often come to me as a referral gastroenterologist. So causes, I'm not gonna read these, all these causes we think about adverse reactions to food, chronic neuropathies, and other things that I'm not gonna address because they're less related to tonight.
So inflammatory bowel disease is actually a histopathological description rather than a disorder. We don't see the inflammatory bowel disease of the type that they see in people. We don't see the type of celiac disease or ulcerative colitis, that is IBD in people.
We've kind of borrowed the term a little bit inappropriately. So it just means, yup, there's inflammatory cells in the bowel. That's all that means.
So probably chronic enteropathy might be a better term for what we're seeing and describing this pro probably a group of different disorders that may or may not be causing inflammatory cells in the intestine, but it's not one thing. It's not a single disease like I was taught a long time ago. We just got excited about doing endoscopy and the fact that we could do this, I think, and that we could take these biopsies and see these things.
So, chronic neuropathy, what happens, and I saw this slide, so it does say IBD, but we have sort of a, a combination of potential risk factors that when they're combined together in a genetically susceptible individual, we do see signs of chronic neuropathy. So a dysbiosis, a disordering of the types and amounts of bacteria and yeast and probably other creatures in the microbiome. A combination of inflammation, so adding these things together in a susceptible individual and they are likely to get a chronic and neuropathy.
We know there's genetic input here. We see it more in some breeds than others. Oh my goodness, the orchies that we see with this that are so hard to deal with sometimes.
So what we're going to, how we're going to influence this, dietary modification, antimicrobials when we need it, immunosuppression if we need it. And I'll touch on this. So, now, we're gonna do Timmy.
Timmy is a case you've probably all seen some version of. Timmy's a German Shepherd dog, a male tyre. He's 10 months old.
And he has a poor appetite, because Billy is vomiting that the owner wakes up too early in the morning. There's kind of froth on the floor. She hears him puke occasionally at 4 a.m.
And he has had diarrhoea for the last 4 to 5 months. She offers him a new feed. He eats it well for a bit and then he doesn't want to eat it anymore.
So, she has tried 8 different commercial brands and also home-cooked chicken and rice. This is typical of our owners, isn't it? They, they chop and choose and keep trying to feed something different and it doesn't work, so they choose something different and then pretty soon we run out of novel protein, foods.
Otherwise, he's OK if she thinks he's a little down at times and doesn't seem to feel very well. She has again tried over the counter probiotics and prebiotics, thinking that will help. My experience is certainly the same as for Timmy's previous vet.
They haven't done much. She tried to, preferring vet, put him on omeprazole for a couple of weeks. Again, a drug, I think we're overusing, choose your cases for omeprazole.
Not everything needs it. Mirtazapine. It helped a little bit, a drug I do quite like, mess.
So, it's to me, physical exam is unremarkable other than a low body condition score 3/9. He's a little thin for a young German Shepherd dog. His muscles aren't too bad.
He's been vaccinated and dewormed. He hasn't travelled out of the country. She's given up, he's not on any current meds or supplements.
He has diarrhoea, closer to 3 times a month, actually, closer to once a week. Once in a while, fresh blood and mucus, and he has pooped in the house. And again, he vomits yellow form in the mornings on these days he's not too keen to eat.
She has decided to feed him cooked rice and chicken for the past several weeks. So, Timmy's problemless, poor appetite, low body condition, intermittent diarrhoea. Billy's vomiting and an unbalanced diet, which I'll show you a bit more about in a bit.
So, for the poor appetite and Billy is vomiting, chronic neuropathy, colitis, and a whole bunch of other things, gastritis, due to drugs, except he's not really on anything that would cause that right now. We need to remember Addison's hypoadrenal corticism can cause these signs. Always think of, always think of hypodreinic corticism.
It's easy to rule out. So, vomiting syndrome, pancreatitis, chronic low grade, yup, possibility. Neoplasia, yeah, he could be a lymphoma, and yes, young dogs can get lymphoma, but this has been going on for a while without getting worse, so less likely.
Diarrhoea with weight loss, chronic neuropathy or colitis. Remember, we always think of weight loss as only being small bowels. Some of the colitis cases will lose weight.
Lhayasia, protein losing enteropathy along with that, pancreatic insufficiency, right breed, right age, possibility, parasitology, parasites, excuse me, could be neoplasia, but we're hoping not and it's awfully chronic. So what are we gonna do? So haematology and biochem, pretty unremarkable albumin's OK.
Nothing on a UA, no faecal parasites on the, on free testing. Cortisol is within the reference range, so it's over 55. There you go.
That's how you rule out hypoadrenal corticism, and I would do that in every GI case. Some of them present just a little off colour with GI signs. TLI is fine.
He's not EPI. A CPL is low enough that we don't think he has pancreatitis. Now, he's low on his folate.
He's low on his vitamin B12, fairly low actually at 108. So, we're gonna update his problem list and add the low B12 and folate. This is telling me.
Yeah, he has, signs of colitis and blood and mucus in his stools. He also probably has an enteropathy cause he shouldn't get a low B12 folate just with colitis. So he, maybe this is contributing to the weight loss that the poor appetite as well.
So he's become just slightly more intriguing now, hasn't he? He's large and small bowel, which a fair number of dogs and cats can be. OK, so this is our poll question.
So what do you want to do next? We'll give you 4 choices. You can give him antibiotics, you can do endoscopy, you can do a feeding trial, you can do ultrasound.
So hopefully, Paula set us up to answer questions on this, and I'm gonna tell you, other than one of those, there's not, the other, there's 3 that are reasonable. One, not so much. Yep, so the poll has now been launched.
About 25% of people have voted, so we'll leave that for about 30 seconds or so just for those to come in. 3 main answers that have been given, you're probably happy to him. Good, I'm very happy.
It may probably led them to that, but. So just going past 50%, so we'll give it another 15 seconds or so just for everyone to vote. OK.
And I can't vote and you can't vote. I almost could have, the, the, the evaluation came up early. I could have evaluated myself before I gave the talk.
So we've had, just over 300 people vote now, so we'll just leave that for a couple more seconds. I think slow down a bit, so we'll we'll end that there. OK.
So we have, the top result with 60% of the votes is a feeding trial. OK. Behind that with 22% is ultrasound.
16% endoscopy and then just a couple on antibiotics. OK. OK.
I will tell you this, oops, OK. OK, I will have to tell you that. I've certainly done endoscopy on a lot of these cases at this time, especially if they're from far away.
And I know that I can't really get this dog or cat back easily into my practise. So they've come from the back of beyond in the Highlands and islands someplace and, and this is gonna be my only chance to see it. So that's not really a wrong answer.
And it will give you the opportunity To find out if lymphoma is present. So if you suspected that a little higher up your differential, that would be a reasonable thing to do. Ultrasound, again, you could look at bowel layering, you could look at the rest of the, the rest of the organs, see if anything else was troubling you.
So, not an unreasonable choice either. I'm gonna start with feeding trial, and I will try to explain to you why. Now, if this This dog was unhealthy, hypoalinemic anaemic, anything else that concerned me, I would not start with a feeding trial, but this dog is relatively healthy other than some of the diarrhoea.
So we're gonna, we're gonna start with that. And you do need to pick your case. So I was, I will say not in every case, but in this case and in many of them when they're otherwise OK, a feeding trial, it can be a really good choice.
OK. This is why, for chronic neuropathies, about 2/3 of them are, and I, that I know that triangle's a little bit deceptive that way, but you have to do volume rather than height of the line. About 2/3, 60%, 65%, depending on which studies you read are food responsive in neuropathy.
So this is part of the reason that you might wanna start with the feeding trial because You have about a 2/3 chance of, of winning right there. And those cases are also the ones that do better. About another 20% or so, are antibiotic responsive and you kinda pick your poison there.
I quite like Tylacine. I used to use a lot of metronidazole and sort of got convinced to switch to Tylain, depends on what you have available and the formulations you have that you can use and what your experience is, what you like. Another about 14, 16%, actually, I didn't even put this down as a differential, are immunosuppressant responses.
So these are the ones that are more difficult to treat. It's the way we used to start 15 years ago. We gave everything prednisolone.
So about another 15% or so we'll need Pred eventually, and they don't do as well long term. And then we have the small percent up here at the top that You don't win with any of these. They're really, really hard to treat and it can be hard to, some of the fibrotic ones are like that.
It can be hard, I don't know where to go with those, but I get about 60 that should say, not 60, about 60% of dogs with chronic and neuropathy will respond to a feeding trial. So, let's consider that. So first, we want to look at his current diet, and I'm apologise, this is slightly busy, but all you really need to look at is the green and red and white.
So, if it's green, it means that his diet, and I figured out a chicken and rice diet for 29 kg dogs, so I might have even gone a little higher to, to meet his ideal weight. So we've got enough calories in him. It's about 1700 calories.
He's got pretty much most of his protein and amino acids are OK. He's a little too low in fat on this, and this is very common that these diets are too low in fat and the 18, colon too, the undifferentiated. That's linoleic acid, which is an essential fatty acid, and many of the homemade.
But I see are deficient in that. Now, in his case, for a young dog who's maybe got a tiny bit of growth left to do since he's a big breed dog, if that's readable for you, he's at less than 3% of the calcium he should have. That's terrifying.
His phosphorus is deficient. His potassium is deficient. He's got about half the potassium he should have for a GI case, that's terrifying.
Zinc is always low in these types of diets. B12 is low. Now, his low B12 in his diet did not cause the low serum B12.
Low serum B12 is caused by enteropathy almost always rather than a dietary deficiency. So when you see that think guts, even though his diet is deficient, think guts because it's most likely a gut problem. So, This chicken and rice, this quote unquote bland diet that we sometimes like to use, be aware, it's a pretty deficient diet.
I would not ever leave a dog on this, especially a growing dog, for more than a week or two, and a growing dog, possibly not. If I absolutely had to, I would get that. I did pretty fast.
Especially that low calcium that bothers me. OK, so we'll come back to our diet choice for him in just a bit. I do wanna mention this intermittent bilious vomiting that he's doing.
So we're gonna rule out that he didn't like get into the rubbish on those nights, that he, that he vomited overnight. We're gonna see how he responds to the feeding trial, but this is, these are the cases I always ask, how late at night are you feeding his dinner? And often it's like 4 or 5 p.m.
They, they feed the dog dinner and then they The news or something and have their own dinner and that's it for the dog. A great majority of these cases, if you give them a late night snack or meal, sometimes that's all it takes to get them through the night. It's a disorder of fasting motility, so they just don't cope with having empty guts for too long.
So, the other thing you can do, add some more metoclopramide half an hour before that late night snack or meal. Remember, metoclope doesn't have a long duration of action, but I have found that it will seem to help these dogs get through the night. I think if you just help the gastric emptying, which metoclopramide does.
I'm not. Really using it as an anti-emetic so much as as a pro-kinetic for the stomach and, and the duodenum. So if you can get the stomach into their intestines, they seem to be happier so the food into their, ah, the food into their intestines, not their stomach.
That's a bad thing. Other medications, Ranitidine may help some of them, some, some people have used omeprazole and these again, long, I don't like long, long-term omeprazole, and these. If they respond to the metoclopramide or the Nitidine, they often need to stay on it for a long period of time, and I don't like leaving dogs on omeprazole for months and months.
So I would probably choose metoclop and then add ranitidine to it if I needed to. But the late night meal works on about 5 to 2/3 of them. OK, so I wanna talk a little bit about, excuse me again, about adverse reactions to food, which I mentioned earlier.
We're looking at Food allergens being the larger particle size, so we want something under 15 to 20. The foods that most often cause reactions are the foods fed most often. So we know for cutaneous reactions, for skin reactions, beef, dairy, wheat, and chicken, and dogs.
There is no such thing as a hypoallergenic diet. This is just something I pulled off the web, a commercial over the counter diet that calls itself hypoallergenic, which is rubbish. It's not.
If your dog has had that ingredient, it's not hypoallergenic. So again, things that for cutaneous reactions, dogs, beef, dairy, chicken, just because it's what they get a lot, cats, beef, fish, chicken, you can stick lamb and dairy in there. This was, I think it practises in the US, so this was probably a US study, so it's whatever they've been fed.
So the other thing I think for GI disease that is different for us internists than for the dermatologist is you get a direct interaction of the gut and the diet. And I think there may sometimes be things going on that we don't completely understand. I'm not sure it's all true allergy.
Or even true intolerance. I think there's an interaction. This is not evidence-based.
This is my guessing and my experience that I think there's an interaction directly with the gut and the food sometimes. Sometimes they can go back on their previous diet, where less of the skin, well, some of the skin cases, but not all of them can. So again, about 2/3 respond to diet.
Nice if you wanted to do the endoscopy and get some histopathology and it's always nice to, to know what it is. It's probably gonna come back moderate lymphocytic placytic enteritis and colitis like they all do. Well, not all of them, but That almost is what we call background noise, especially if it's mild.
We kinda now think that the, especially the mild lymphocytic plasmaytic IVDs, we don't think that means anything. So histopathology doesn't predict a response, as long as you're not seeing like dilated lactals and picking up lymph ajectation. But before the chronic neuropathies, you can't tell whether or not they're a food responsive based on that.
I still like to do it. It gives me possible answers that I didn't have before. Is there fibrosis?
Is there lymphoma, things like that. But it doesn't tell you if a quote unquote IBD or chronic neuropathy is gonna be food responsive, antibiotic responsive, or steroids responsive. So, I wanna talk a little bit because I still get weekly, sometimes more than once a week, requests for a diet based on Testing for IGE for food allergies, specifically food allergies, not, not some of the other derm things because then obviously skin testing is useful, but it is not useful for food allergies and somehow owners have got hold of the idea that they want it and I often have requests sent to me by vets where the owner has maned a food allergy testing.
It doesn't test for non-IGE allergies. There's high incidence of false positives. The negatives may be negative, so if you have a negative, maybe that's a food to try, but even then it doesn't always work.
So the serum IgE in the US, they have a saliva one and all of these are completely inaccurate. There is a UK gas A neurologist who says, you can just send me 50 quid and I'll make it up for you. So I feel like that would be a good retirement job for me.
I'll just make up food allergy responses. These are not useful. They are a waste of money.
The only way to know if there is a diet-related skin disease or GI disease is to do a dietary restriction. And possibly provocative exposure or a challenge. So it has to be based on what they're actually.
I have owners who have requested this and then actually will tell me, well, the diet said he can't have chicken, but he actually can. So they even figured out it doesn't work. OK, I'm just gonna mention that a little bit about what we choose again, I prefer the hydrolyzed diets for these.
You do need to get a good diet history. Find out if they're being given. Anything they can chew up, dental shoes, anything else, .
Hydrolyzed diets or single protein diets with nothing else added, GI a couple of weeks at the most is usually good. The cutaneous adverse reactions to food go longer. I'm glad I'm a gastroenterologist, not a dermatologist.
We don't have to go as long. OK. Technically, to know what they were reacting badly to, you would add a second protein for 3 days, see if they had signs, it takes 3 to 5 days, see if they get the diarrhoea again and then take the food out, see if the diarrhoea responds.
I have very Very, very few, very, very few owners who want to do that. Once we get the diarrhoea or vomiting or both cleared up, most of them don't wanna go there. The if the owners don't wanna challenge and I'm happy they're on a complete and balanced diet, a good hydrolyzed diet, a novel protein diet, I'm happy to leave them on that diet forever.
So what did we do with Timmy? We've got our three main choices, hydrolyzed commercial, novel protein commercial, homemade cooked, I would add fibre to him with a homemade cooked, I might add fibre to one of the other two in time because he had signs of colitis. I'm gonna Supplement the cabalamine, the B12.
We did an initial, one or two injections and then switched to orally, oral cabalamine on him. We also gave him a little folate just cause he was low on it. He probably would have been fine just on the diet.
The folate would have come on. Now, homemade diets, even if computer balanced, which is what I can do for you if you have a client or a case that needs it as scan, some other nutritionists, it's only as good as the compliance with the database. So if you, if I tell you that I want to include white rice that's cooked, the white rice nutrients I have have to be identical to what you're buying at Tesco's.
Are they? Maybe, maybe not. The white fish that you buy has to be identical to what's in the database, and it's hard to have that exact.
Say for instance, the amount of omega 3s in salmon depends on what water they're in and what season it is. There's a lot of variability here. So there's no feeding trials on homemade diets.
The pet that you put on that diet essentially is having the feeding trial done, whereas commercial diets, good quality commercial diets may have had feeding trials already done. Food quality. Owners don't always owners don't always give what we tell them to give.
I think good compliance is about 16% on home cooked diets. A lot of people pay for a diet and then make it up as they go along. We also don't know about nutrient bioavailability.
So if I mix potatoes and peas into a diet, what have I done to the touring? I can't tell, and it is becoming more and more of a concern. So what have we done for Timmy?
We went hydrolyzed commercial for Timmy. We added a late night feeding because of the bilious vomiting. Again, I said we went ahead with the B12.
Saw him back in a couple of weeks, done well. He's had no vomiting. The Billy's vomiting is sorted with him.
We didn't have to add any medication. Stools have been the most normal they've ever been. The owner hadn't realised that his normal stools were actually a little soft.
And he'd actually gained 0.5 kg, which is pretty good in a couple of weeks. So he's gone back just from strength to strength on this.
And if you want to write down your questions and I will turn it back over to Libby and Paul just for a bit. I just, before, before we go into the questions, I just wanted to share a little bit, just very, very briefly, just one slide, introducing our, range of Purina veterinary diets. So Marges outlined to you the key nutritional factors, in the management of diarrhoea and just to, to, raise your awareness really that we have a full range of concise and a comprehensive management for diarrhoea in our gastrointestinal range, which is part of our pro plan veterinary range and we also have the for the flora.
So the the probiotics that Marge mentioned there as well. So if you'd like to find out any more about the the pro plan veterinary diets, do please contact your Purina representative, or you can direct any queries to me through Paul and the team at Webinar vet. So I'm just going to hand you back now.
And and to Paul. So thanks again, Marge. Thanks everybody.
Pleasure, Libby. Thanks, Libby. Yes, we'll send out a link to find out more information when the recording is available, which should be in the next couple of days.
But thank you as well, Marge, an excellent, presentation, very informative. It's fantastic. We do have a number of questions coming in, so, to the community, if you do have any questions that you've thought of, please do feel free to submit them now, we'll get through a few.
An interesting question came in March, regarding the poll question. Bridget's asking why not do a faecal analysis at this stage. I did have in, I I kinda skimmed through our diagnosis a bit quickly cause I knew I had too many slides.
We did, we did have an, faecal analysis for parasites. I don't know if you know for, meant for enteropathogens. Certainly, if the dog had been fed a raw food, I would have been on that a little quicker, .
So we did eliminate the chance of parasites. We didn't do any pathogens on him. I actually haven't done that as much as I used to.
I used to do it fairly routinely. I think. Possibly one of the reasons I don't do that as often.
I wouldn't have done it in this case cause he didn't really fit a Campylobact or a salmonella, or a Clostridium enterotoxic dog. If he had been a bit more acute and a bit more severe, I would have added that, although we now know that we, what we used to think we knew about the bacteria in the intestine. It was really limited to what we really know now.
So I think culturing is, unless you really suspect an orotoxigenic E. Coli or, or salmonella would probably do less of that, but that's a good point, yeah, in a, in a slightly different presentation, that would have been definitely indicated. That's great, thank you very much.
I hope that helps, Bridget. That's certainly, an excellent and thorough answer. We have a couple of good questions, coming in actually regarding dealing with pet owners.
So, the other side of the coin. So Rosemary's asking how would you deal with owners, who's pets on a raw diet who has diarrhoea, and Hillary's asking, how do you persuade clients that a hypoallergenic diet is not actually hypoallergenic, as you mentioned. Let's see.
Repeat the raw diet question again. I got distracted with the hypoallergenics. No problem.
So how do you deal with owners whose pet is on a raw diet and has diarrhoea? So a little bit, OK, . When they have the diarrhoea, that, that, that is sort of awkward, isn't it?
If they are feeding raw, we'll leave it for a dog that doesn't have diarrhoea just for a second. A lot of the advocates of raw feeding are quite emotional about it, and quite defensive about it. So I usually don't try to get head to head into an argument about that because you're, you're not going to persuade them.
This is not a true intellectual decision they've made. It's an emotional decision they've made that they are then defending, . That's typical of a lot of decisions all of us make about things.
Unfortunately, it's typical of politics. So, what I have on that, is a a handout on if you want to feed a raw diet, please know these things about it. If it's homemade, it's probably deficient.
If it's commercial, it may be complete and required nutrients, although, there isn't really, feeding trials done on most of them. I'm not sure. Any of the UK ones have had true proper feeding trials done on them so that they are limited that way and then I have information on some of the contamination in them.
Even some of the commercial ones have now been shown to potentially be contaminated. So I guess I would probably provide them with that information, say that feeding raw, is a, is a risk factor for causing diarrhoea, and that would they at least consider Cooking that food for a diet trial if they wouldn't use a commercial one. It's, it's a difficult situation.
There's not an easy, easy answer for that. And the other question I think was how do I convince them that what they fed over the counter is not truly hypoallergenic. Couple of ways on that depends on which product it is.
Some of that would be a discussion about what, and I, this is a hard one. I just had to go around. I had a poor vet that I was working with whose owner does not understand this, and I, and we can't get the owner to, to understand that she can't feed a different protein every week, that that doesn't prevent her dog from, from having allergies.
. That, I guess the example that I gave, that it's for your specific pet and that if the first ingredient is chicken, it's pretty likely that your dog or your cat has had that in a, in a previous diet, and therefore, it won't be a novel protein for that pet. I don't even use the word hypoallergenic. I hate that word other than where it's a proprietary trade name.
It doesn't mean anything ever. Was there more to that question that I've now forgotten halfway through my answer? No, I think it, it was just about how do you manage the clients in that respect and and move them sort of away or just or.
Yeah, I guess to explain explaining what we think we know about food allergies. Yeah. No, that's, that's great.
That's really helpful. Thank you. And, interestingly, we did have a webinar on the site, which is free access for everyone, a week or a couple of weeks ago, on raw feeding.
Very informative by Sean McCormack, so I'd definitely recommend taking a look at that as well, as you mentioned, Marge, it is, a very emotional topic for, for some owners. Interesting question here from, Sibula said, how much food, do you give on a, a provocation trial? Is 30 grammes per 10 kg of dog enough?
Yeah, probably. I don't think we have strong science behind that. I think we have anecdotal evidence and I was taught by my mentor like 1 to 3 tablespoons of which would, you know, 30 grammes depending on the size of the dog.
Yeah, it doesn't seem to take very much. Certainly when we do have a true food allergy, especially an IGE mediated one. It doesn't take very much and the response can be quite rapid.
Some of the animals will almost vomit on your feet while you're giving them and sometimes it's quite quick. We can get delayed food reactions, which is why you do need to feed them for several days. You can get, type 4 reactions, 2s and 4s, so it can take 48 to 72 hours in some cases, which is very hard for the owner to understand too that that.
It still can be the food two days later, so that's why we want to go a little bit longer, but the generally the challenge can be quite small if it's a true allergic reaction. If it's the food interacting with the gut in some obscure way, I don't know if we know the answer, but if it's true allergy, it does not take much. Yeah, sure.
No, that's really helpful, thank you. The slightly different question here, which is I think's going to be an interesting one. Clive's asking, do you think the fluoridation of domestic water supply affects the the biome?
Good question, and I guess where we have a whole population where that's included, that you don't really have a control, so you would actually, and then there would, you can't answer that, to be honest, you really can't answer that question because if you compared, say, a population in the US where fluoridation is very common, to maybe a population in one of the African countries to where it's less No, it's not less common. It doesn't happen, to where it doesn't happen. You also have difference in genetics, you have difference in fibre content of the diet.
I, we don't have two comparative populations as far as I know that do and don't have fluoridation to be able to answer the question. No, that's a good point. I think in in the UK it's generally fairly similar throughout, although in the Midlands, there is slightly more fluoridation of, of the domestic water supply.
So it could be interesting to see if there would be any differences there. But as you mentioned. You need a big population, and founders.
Lots of, lots of variables there to think about. The other thing is we do know that your microbiome is pretty much your microbiome and it's very hard to shift it. The probiotics will shift it, but if you discontinue a probiotic, you will revert back to whatever is your normal within a couple of weeks and you will persistently be whatever is normal for you.
And there are people who are more susceptible to responding to probiotics and people who have a very, a very persistent, microbiome that doesn't respond to probiotics. So this also makes a probiotic testing hard to, to, to look at. So I don't know if that would also be true of, of fluoride or not, but, certainly, Some of us don't shift as easily as others, and the other thing that I think is always fascinating that you may, the rest of you may have heard of is that you are more likely to have a similar probiotic to your pet than you are to your neighbour.
I don't know why exactly. We don't want to think about that too hard. Absolutely interesting though.
We've got a question here from Henry. Yeah, in instances of chronic diarrhoea when no approach has seen a resolution, but it is the only clinical sign, is it ever acceptable to just live with it? Well, I guess the first thing would be to make really, really sure that there isn't any dietary intervention that you can make.
. And if it's and you need to determine is it large bowel? Is it a small bowel? Is it both?
I have had some that, oh, we did kinda go around the houses on hydrolyzed diet and finally ended up on one of the very ultra hydrolyzed diets. And all of a sudden this dog did well, and this, I usually with GI cases, I will say that it seems to make less of a difference than it does for the derm cases, but I saw a dog a week and a half ago that, yeah, once they got him on one of the ultra hydrolysis, he did really well. So, I don't give up easily.
I did have another dog I saw on the same day that has a lot of fibrosis in his gut and some of those are really, really hard and it can be. Kind of coming down to it. I, I just live with it.
But again, the order that we do this in is usually diet and being really careful with what we go into the diet, really, really good diet history because there can be little things that you miss, that are making a big difference. I had one owner when I was a resident who, I don't wanna say that wheat intolerance is very common because it's not, but this shar pei actually was wheat intolerance and the owner didn't understand that giving him the corners of his toast still counted. Currently there's no wheat in the corners of your toast.
So just making really sure of that, going on to try something like Kylosin. I hate leaving them on long-term antibiotics, but I have had cases I had to leave on for months. Things like Prad, mycophenolate, other immunosuppressants, again, terrible side effects potential with those and the long term.
Prognosis is not as good. Most of those dogs get put to sleep in 2 to 3 years. But yeah, if none of that works and the owner will live with it.
Sometimes that's the best he can do. But we have lots of things to try first, so I would, you know, eliminate every, every treatment possibility you can before you give up and have an owner live with a dog especially a dog with a cat as well with diarrhoea cause that's pretty hard on everybody. Yeah, absolutely, and I think you, you mentioned it quite early on in your presentation.
I guess it's quite important as well to get that across to the owner that a full history is really key. Absolutely excellent. We've got lots of very positive comments coming in.
Thank you, lovely webinar, really enjoyed it, very informative, great lecture, all very, very positive feedback, which is great to hear, Marge. That's nice. Just a, a couple more questions then cos I'm, I'm, conscious that we have, slightly surpassed the hour mark.
That was sort of my fault too. Now it is an excellent webinar though. Got a question here, what are your thoughts on faecal transplants?
It's come up a few times recently. That's a really interesting topic, . I think once we know a little bit more about it, there have now been some case studies and some individual small studies looking at it.
Scott We in Canada is doing some really good work on this. I, I attend every one of his lectures I can get to, . In people, it has shown good efficacy for some of the quite antibiotic resistant Clostridium difficile.
There have been a small case study in CAS where it showed some improvement and we're getting more and more anecdotal information about the improvement. Right now, I think Scott Weiss on the, he's at Guelph, the university there at Guelphett school. I think he's got a protocol on their website that is possibly worth looking at.
. We need to know a little bit more how to decide on the donors for that. And people, I think there is one company that's making a commercial product rather than, you know, taking it from an individual and Using a dedicated blender, for, I, I think there's definitely a future for this, and I think it's gonna be quite exciting. We need to get past the yuck factor, and decide how we're doing it.
So something like a commercial company who, who has a good standardised product could be very promising. Fantastic. Thank you very much, Marge.
What we will say then because we are pushing on for time, so if you do have any questions, any more questions, what we'll do, if you send them into office at the webinar vets.com, and we'll work with Purina and Marge to, to get as many of these answered as possible and, and try to put something together to be sent out within the next week or so. Marge, thank you very much again.
It's been an, an excellent webinar, we've really enjoyed having you, so thank you. Oh, thank you, Libby. And yes, thank you, Purina as well for making this free access.
Thank you, Libby. Thank you very much, guys. And thanks everyone for coming on and joining us tonight.
