Visiting Vet: When it’s uncommon

Dogs get upset stomachs all the time; occasionally, it’s more.

Courtesy Wikimedia Commons.

There’s a saying in medicine: Common things happen commonly. When a dog presents with vomiting and/or diarrhea, the most common diagnosis is “nonspecific gastroenteritis.” In other words, the patient has an upset stomach, and we don’t really know why. “Has he had anything unusual to eat?” we ask, knowing owners sometimes treat pups to inappropriate foods (like the Chihuahua whose parents fed him steak, mashed potatoes, gravy, cake, and ice cream for his birthday, then were surprised the little guy got sick). “Could she have gotten into garbage or compost?” we ask, knowing dogs relish the rotten remnants they find there. “Does he run loose? Has he been to the beach?” we continue, all in search of possible sources of “dietary indiscretion” — medical lingo for eating something yucky.

In many cases, we can’t pin down the initiating cause, hence the adjective “nonspecific.” Unless there is high suspicion of exposure to toxins, or ingestion of an object that might cause obstruction, aggressive diagnostics are rarely warranted at first. When children come home from school with a stomach bug, or throw up after overindulging on Halloween, we might consult the family doctor, but rarely rush to the emergency room. We give whatever medications our doctor recommends, offer bits of toast, or sips of flat ginger ale, and wait for it to pass. It’s pretty much the same with dogs (except no ginger ale). Most cases resolve quickly with symptomatic care — medications to control vomiting and diarrhea, withholding food briefly, then feeding bland food in multiple small meals until the episode is past. Over recent months I have seen dozens of animals with nonspecific gastroenteritis, most of which had the expected rapid resolution. But not all of them. I’m going to tell you about two: Dyroy, an elderly German shorthaired pointer, and Amado, a young puggle ( that’s a cross between a beagle and a pug).

Dyroy came in with a one-week history of intermittent vomiting and diarrhea. She had lost a little weight, but eagerly ate liver treats I offered. She stood a bit hunched, like her belly or back hurt, but exhibited no discomfort when I palpated her abdomen or spine. We decided to start with symptomatic treatment — an injection of antivomiting medication, oral antidiarrheal pills, and instructions on how to institute a bland diet.

Amado was first seen at another veterinary practice after one day of vomiting and poor appetite. That doctor did exactly what I would have done. The same antivomiting injection. The same bland diet. They even went one step further, taking abdominal radiographs. Young dogs, like young children, will put anything in their mouths, and chew up and swallow inedible objects. Stuffed animals, socks, rocks, balls, toys. Because Amado was only a year and a half old, the risk of foreign body ingestion and obstruction was greater than in a mature dog. Young dogs are also prone to a life-threatening condition called intestinal intussusception where the intestine telescopes in on itself — another good reason for that x-ray. But the films looked normal. Amado went home with similar instructions to those I had given Dyroy.

Initially Dyroy seemed to improve. She was eating more, but her stools were still abnormal. Within a week, she took another downturn, passing fluid diarrhea with bits of undigested food. Returning the dog for a recheck, Dyroy’s mom reminded me that back in March, she had noticed a small lump on the right side of the dog’s neck. I palpated Dyroy’s right mandibular lymph node. It was slightly enlarged. I felt the other side. Also slightly enlarged. I then checked the nodes in her armpits, groin, and hind legs. All were slightly larger than normal. It’s called generalized lymphadenopathy, and the most common cause in dogs is cancer, particularly lymphoma.

Common things happen commonly. With a presumptive diagnosis of cancer causing her gastrointestinal woes, and considering her advanced age, we decided to focus on palliative care, hoping to improve her quality of life but without aggressive diagnostics or treatments like chemotherapy.

Like Dyroy, Amado improved initially, but continued to have bouts of poor appetite and vomiting over the next month. His owners brought him in one weekend on emergency. He looked pretty good to me. I reviewed the radiographs, concurring all looked normal. I was seriously thinking about just sending him home with a second course of the same treatment, but his family was so worried, I decided to reassure them by running some tests. We started with a Lyme test while they waited. Nope, no Lyme disease. “Go on home while I run the other lab work,” I said. “I’ll call you if anything is abnormal.” An hour later I had to call and tell them Amado was in severe kidney failure.

How could this happen to such a young dog? Ingestion of certain toxins, like antifreeze, will cause kidney failure, but Amado lived in a fenced yard and had no known exposure to antifreeze. Besides, antifreeze toxicity has a much more rapid course, with exposed animals dying within a week. Pyelonephritis, i.e., bacterial infection in the kidneys, or another infectious disease, leptospirosis, could be the cause. Even tick-borne disease remained a possibility, despite my in-house Lyme screening. Neither Amado’s history nor clinical presentation really fit those, but they would need to be ruled out with further testing. By far the most likely diagnosis was some congenital problem with his kidneys. In other words, he was likely born with abnormal kidneys, which were now failing. I referred Amado to specialists where ultrasound supported the tentative diagnosis of congenital kidney problems, while other tests ruled out the other possibilities.

There is no cure. If Amado were human, he would be on dialysis while awaiting a kidney transplant. After several days’ hospitalization and intensive care, his family has brought him home. Both Dyroy and Amado’s families will continue supportive care, helping their dogs enjoy whatever time they have left. Sometimes what first looks like something common turns out to be something uncommon … and uncommonly sad.