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THENEXTTWODOGSHAVETHESAMEDISEASE–WHATISMSU#85- 4yrFGerman信息：4歲母德國牧羊犬 Diarrhea/weightloss–4HPI:Stoolssoft,nomucusorHaslost5kg Metronidazolenothelpful OraltylosinhelpedforfewmonthsPE:DogisMSU#85-FatabsorptiontestsnormalIntestinalChronicmildeosinophilicenteritiswithvillusatrophy, smacytosis,mildtomarkedlactealdilation–“IBD”TAMU 2yrF(s)信息：2歲母（絕育 Vomitingfood&bilesince4months主訴：從4月齡開 食物和膽 Loudborborygmus,espafter現(xiàn)病史： 較大尤其是 Repeatedvomitingcauses多 引Conditionfluctuates,notsureifpriortreatmentsEndoscopicbiopsies7monthsago:7個月前內(nèi)窺鏡活檢：正Nowvomitsatleasteverythird現(xiàn)在至少三天出現(xiàn) TAMUCBC,U/A,Abdominalradiographs,Bariumcontrastradiographs,ACTH-stimulationtest,andthyroidpanelareallnormalSerumchemistrypanelnormalexceptforhypercholesterolemia(458mg/dl)除了高膽固醇血癥（458mg/dl 生化都正TAMUEndoscopy duodenal Histopath= “SmallIntestinalBacterial tinalBcterialOvergrwth抗生素反應(yīng)性腸ANTIBIOTIC-DIARRHEA抗生素反應(yīng)性腹Whatisit(andwhythename這是什么（以及為什么病名發(fā)生變化Notan并非是“過度生長Nosuchthinginthe在犬不會出現(xiàn)這樣的情Whatisit(andwhythename這是什么（以及為什么病名發(fā)生變化Notan 并非“過度生長Clinicalsignsdependuponanin betweenhost’simmunesystemandbacteria,especiallythosewithapredilectionforcausingtroubleWhatclinicalsignsdoyouMayseeanyofthediarrheaweightloss體重減anorexia厭Howdoyoudiagnosethis如何診 組織病理 細胞 細菌培 鈷胺素/葉犬小腸內(nèi)細菌生長過本研究顯示對于犬葉酸和鈷胺素濃度的異常很普遍，沒有診斷價值。Cobalamin/folatetest approx鈷胺素/=Cobalamin/folatetest approx鈷胺素/=Treatmentof20kg治療20kg的20ug/kg/wk=40020微克/公斤/周=400微克/100mlbottleof1,000ug/ml=Cobalamin鈷胺Cobalamin/folatetest approx鈷胺素/葉酸測試=Treatmentof20kgdog:治療20kg的–20ug/kg/wk=400微克/公斤/周=400微克/–100mlbottleof1,000ug/ml=100毫升一瓶，1000微克/毫升 1bottlecantreat20kgdogfor250weeks;canget12bottlesfor$36一瓶可給20公斤犬用250周 可買12–100pillsof1,000ugeach= 微克，每片藥Howdoyoudiagnosethis 組織病理 細胞 Responseto

HowshouldyoutreatthisBroadspectrumantibioticsaffectingGram-Gram-positive,aerobicandanaerobicYouareNOT“sterilizing”the腸道無法“滅菌YouaresimplydecreasingthenumbersofbacteriasothattheGIimmunesystemcandoitsjobHowshouldyoutreatthis如何治BroadspectrumantibioticsGram-negative,Gram-positive,aerobicandanaerobicbacteriaCanusemanydifferentCephalosporin, YBETWEENDIETANDSometimescombiningdietarytherapywithantibioticsallowsbettercontrolthancanbeattainedwithantibioticsDIETSNovelproteinHydrolyzed水RoyalCaninlimited Purina Hills NON-PLECHRONICSMALLBOWEL y 大約 y抗生素反應(yīng)性腸病大約Steroid-responsive y<類固醇反應(yīng)性腸病約食物反應(yīng)

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類固醇HowLongDoYouHaveToTreatWithAntibiotics/DietBeforeYouCanSayTherapyIsorIsNotWorking?有效或者無ANTIBIOTIC-RESPONSIVEHowshouldyoutreatthis如何治療Ifthepatientisreally,reallyHowshouldyoutreatthisIfthepatientisreally,reallysickandyouwillprobablyonlygetONEchancetotrya3-4weektherapeutictrial,thenyoushouldbemoreaggressive:如果動物十分嚴重，而且你可能只有一次3-4周的治療性診斷，那么你的治療需要更激Metronidazole+Enrofloxacin甲硝唑 about0.5weekabout0.5weekupto3weeks最多3

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Howshouldyoutreatthis如何治Whatshouldyoudoifthetreatmentappearstowork?如果治療看起來有效果你會怎么HowshouldyoutreatthisWhatshouldyoudoifthetreatmenttowork?Trytostoptheantibioticsandseeifpatientwillmaintainondietalone嘗試停止使用抗生素并且觀察動物單靠飲食能否維It’susuallyeasiertoMAINTAINremissionthanitistoATTAINCURECONTROL控制HowshouldyoutreatthisWhatshouldyoudoifthetreatmentappearsTrytostoptheantibioticsandseeifpatientwillmaintainondietaloneThepatientwithintermittentsigns出現(xiàn)間歇的癥狀抗生素反應(yīng)性腸WtditrtoTrytostoptheantibioticsandseeifpatientwillmaintainondietalone嘗試停止使用抗生素觀察動物單靠飲食能否維持Thepatientwithintermittentsigns出現(xiàn)間歇的癥狀Thepatientwhichquicklyrelapses癥狀迅速復發(fā) Moreandmore“IBD”patientsarecontrolledondietarytherapyand/orantibiotictherapy–thesteroidclubisSHRINKING,Shrinkingshrinkingshrinking,shrinking,Sig:1.5yrFsFrench DiarrheaandpoorweightHPI:Diarrheabeganat7-8wks Abnormalstoolspresentconstantlysince2Endoscopies/biopsies:Tx:steroids,NosubstantialWHATDOESTHISHISTORYSUGGEST? 11yrM(c)EnglishSheepdog32.3kg信息：11歲絕育公犬英國牧羊犬32.3公斤 Weightloss/diarrhea Diarrhea/wtlossbegan2monthsSoftstoolswithout Lost2.5kg體重下降Metronidazole,prednisolone,andnot ，PE:BUN=Sodium=TCO2總CO2=

10mg/dl(8-147mEq/L(138-3.3mEq/L(3.5-14mmol/L(21-Cholesterol380mg/dl(120- 轉(zhuǎn)氨酶=

2.9gm/dl(2.4-403IU/L(< 443IU/L(<AbdominalUltrasound:腹部超聲“HepatomegalyconsistentwithexogenousUrinalysis:尿1.010specificgravity1.010尿Everythingelsenegative其它NofecesavailablemendfurtherFecalexaminationLiverfunction EndoscopicbiopsiesofGItract+胃腸道和/mendfurtherFecalexaminationLiverfunction EndoscopicbiopsiesofGItract胃腸道和/Owner:Hydrolyzeddiet水 Cephalexin(laterTylosin)Hydrolyzeddiet水 Cephalexin(laterTylosin)4weekslater:NorealWHATOTHEROPTIONSCANWECONSIDER?還有其它考慮

TLR’sarepartoftheinnateimmunesystem.Theybindtodifferentbacterialligandswhichcausesstimulationorsuppressionofvariouscytokinesandeithermaintainstoleranceorcausesinfl Feedlivebacteria Needlotsofbacteria(>1,000,000,000) Thestrainisasimportantasthe種類很重Needlotsofstrains(notjustone)需要很多的種類(不僅一種Effectlastsaslongasyoutake只有一直服用益生菌才會有效 Thinkhelpssomechronicdiarrheas思考（？）對一些慢性TheMarchofGastroenterology步硫唑嘌呤苯丁酸氮TheMarchofGastroenterology腸胃病的進TheMarchofGastroenterology腸胃病的進TheMarchofGastroenterologyFecalTrans byDrScottWeeseJVIMFreshlypassedstoolcollecteda.m.oftx.Homogenizedwithsaline(1partstool/4partssaline)andpassedthroughasieve.Fecal ntationbyDr.ScottWeese,Ifuppergiendoscopyisbeingperformed,0.5ml/kgofsuspensioncanbeadministeredperendoscopeintotheduodenum.Ifendoscopyisnotperformedbutasmallbowelcomponentis ed,administrationofastool-cannedfoodcombinationconcurrentwithfecalenemacanbedone. 1yrM(c)信息：1

29.5kgHPI:Episodesbegan6monthsHas3daysofdiarrheaevery2-3weeks+hematochezia/mucusHaslost3.4kg體重下降3.4kgMetronidazole&highfiberdietnotHPI:Previousbiopsy:“Moderatetomarkedlympho eosinophilicenteritiswith... Hypoallergenicdietfor10days;then120mgPrednisolonepluscimetidine:nohelp Dognowhasapoor Calcium鈣=Sodium=Potassium=TproteinT=Albumin白蛋白=

0.8mg/dl(<10.0mg/dl(9.3-147mEq/L(138-4.0mEq/L(3.8-5.6gm/dl(5.5-3.2gm/dl(2.5- 956IU/L(<

n:Home-madehypoallergenic1yearlater:hashadonewhenhadadietaryWhatwerethe“clues”thatadiagnosisofinfltoryboweldiseasewasalmostcertainlyWRONGinthisdog? 1yrM(c)信息：1

29.5kgHPI:Episodesbegan6monthsagoHas3daysofdiarrheaevery2-3weeks+hematochezia/mucusHaslost3.4kgMetronidazole&highfiberdietnothelpfulNormalTLI,cobalamin,&HPI：開始于6個月前；每2-3月會腹瀉3DOESTHEDISEASEFITTHEPATIENT?這個動物是IBDDOESTHEDISEASEFITTHEPATIENT?這個動物是IBDIBDisprimarilyadiseaseofmiddle-agedtoolderdogsIBD主要發(fā)生于中老年DOESTHERESPONSETOTREATMENTFITTHE對治療的反應(yīng)與IBD相符嗎DOESTHERESPONSETOTREATMENTFITTHE對治療的反應(yīng)與IBD相符么SteroidsaregenerallyconsideredeffectivetherapyformostcaseswithIBD類固醇對于大部分的IBD病例通常是有效HPI:Previousbiopsy:“Moderatemarkedlymphosmacytic,eosinophilicenteritiswith...lymphangieia”Hypoallergenicdietfor10then120mgPrednisoloneplusno DognowhasapoorHowdidthepathologistcomeupwithsuchawrongdiagnosis?“...they[clinicians]expectadefinitiveanswerback...theywantadiagnosis.Thereistremendouspressureonustocometoaconclusion...andwehavetoresistthat,becausesometimesyoucan’tmakeanexactdiagnosis.” pages192-193,J.WHENSHOULDYOUBIOPSYAPATIENTWITHVOMITINGOR WHENSHOULDYOUBIOPSYAPATIENTWITHVOMITINGOR Shouldthepatienthavebeenbiopsiedinthefirst 是不是應(yīng)該在第一時糞便檢非浸非浸潤性：治療性試浸潤活

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High October十Sig:2yrM(c)Labradorretriever信息：2歲絕育公犬 CC:Vomiting HPI:Began6monthsago:food1-7hoursafter Contrastrads,ACTHstim,TLI,upperendoscopy/biopsy“Stomach...Thelaminapropriaexhibitsaminimaltomildincreaseinlymphocytesandsmacellswithrareeosinophilsandmastcells....Duodenum:Eighteenfragments...exhibitaminimaltomildincreaseinthenumber smacellsinthelaminapropria... 4.4mgplusmetronidazole,sucralfate,famotidine10： 4.4mgplusmetronidazole,sucralfate,famotidine bloodinstool,weak,2weightloss,pittingedemaoffrontlegSalmonellosisPittingedema:1st:“pyogranulomatouspanniculitisanddermatitiswithintralesionalfungalhyphae”2nd:“granulomatousdermatitiswithintralesionalfungalorganisms”真菌芽腫性皮炎Commission“Thisisthetendencytowardactionratherthaninaction.Suchanerrorismorelikelytohappenwithadoctorwhoisoverconfident...butitcanalsooccurwhenaphysicianisdesperateandgivesintotheurgeto‘dosomething.’”要積極主動而不是。這種錯誤更常發(fā)生page169,J.AWrongDiagnosisCanBeMuchWorseThanNo錯誤的診斷要比沒有確診更糟Sig:4yrFYorkshire信息：4歲母約克夏梗1.8公斤 主訴：腹瀉

1.8HPI:Diarrheaandanorexiafor1Hematocheziaseenonce便血一次Intermittentvomitingnoted有間歇性 WBC白細胞=(6,000-

45%(35-Segs=18,954/ulLymphs淋巴細胞= BUN=Creatinine肌酐=Calcium鈣=Sodium=Potassium=

13mg/dl(8-0.5mg/dl8.4mg/dl(9.3-140mEq/L(138-4.2mEq/L(3.5-Totalprotein=4.9gm/dl(5.5-Albumin白蛋白= 轉(zhuǎn)氨酶

2.7gm/dl(2.5-20IU/L4lain) 4硫酸鋅漂浮法Fecalcytology 1糞便細胞 1孢子/高倍鏡視Abdrads:“RadiographsshowamoderateamountofgasthroughouttheGItract.ThereispoorvisualizationoftheabdominalvisceraduetothegasandfluidintheGIGIEndoscopy:AppearsBiopsy:Severelympho- smacyticduodenitiswithnormal stomachandcolonAssessment: toryBoweln:EliminationMetronidazole(12mg/kgbid)Tylosin(10mg/kgbid)Prednisolone(3mg/kgqd)計劃：排除性飲食甲硝唑(12mg/kg每日兩次(3mg/kg每日一次Dogdoeswellfor6weekswhileonhighdoseofprednisolone Dogdoeswellfor6weekswhileonhighdoseofprednisolone Dogrelapseswhenwedecreasethedoseofprednisolone Dogdoeswellfor6weekswhileonhighdoseof Dogrelapseswhenwedecreasethedoseof Increasedoseofprednisoloneplusadd Anorexiamuchworse,weighs1.4kgAbdU/S:“Hepaticandcraniallumbarlymphnodeswereenlarged...1cminlength...mesentericlymphnodesmeasured1X2cm...Nootherabnormalitieswereseenwithinthe .Theintestinesappearednormal...”腹部超聲：肝臟和前腰淋增大，測量大小為1X2cm.腹腔內(nèi)無其他異常。腸道看似正Biopsy:Liver Intestinemight(?)aEspeciallyImportant

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