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***''Giardia duodenalis''
***''Giardia duodenalis''
***[[Uncinaria stenocephala|Hookworm]]
***[[Uncinaria stenocephala|Hookworm]]
***[[Systemic Mycoses #Histoplasmosis|Histoplasmosis]]
***[[Histoplasmosis]]
**Chronic intussusception in juvenile animals
**Chronic [[Intussusception|intussusception]] in juvenile animals
*[[Lymphangiectasia]]
*[[Lymphangiectasia]]
*Infiltrative disease
*Infiltrative disease
*GI haemorrhage
*GI haemorrhage
**This may occur with hypoadrenocorticism or with other causes of GI ulceration
**This may occur with hypoadrenocorticism or with other causes of GI ulceration
Rare causes of PLE include:
Rare causes of PLE include:
* Small intestinal bacterial overgrowth (SIBO)
* [[Small Intestinal Bacterial Overgrowth and Antibiotic Responsive Diarrhoea|Small intestinal bacterial overgrowth (SIBO)]]
* Hypoalbunimaemia causing intestinal mural oedema
* [[Hypoalbuminaemia]] causing intestinal mural oedema
* Increased activation of tissue plasminogen activator
* Increased activation of tissue plasminogen activator
* Systemic lupus erythematosis (SLE)
* Systemic lupus erythematosis (SLE)
*'''Shar Pei'''
*'''Shar Pei'''
Inflammatory bowel disease and lymphoma are the most common causes of PLE in both cats and dogs but lymphangiectasia occurs much more commonly in dogs than in cats. Chronic intussuscepta (usually occurring secondary to acute enteritis) and endoparasite infection are the most common causes of PLE in juvenile cats and dogs.
==Diagnosis==
==Diagnosis==
*'''Thickened intestines''' may be detectable on abdominal palpation and this finding may be related to the primary pathological process.
*'''Thickened intestines''' may be detectable on abdominal palpation and this finding may be related to the primary pathological process.
*[[Thromboembolism|'''Thromboembolic]] disease''' due to the loss of plasma anticoagulants such as antithrombin III.
*[[Thromboembolism|'''Thromboembolic]] disease''' due to the loss of plasma anticoagulants such as antithrombin III.
*'''Hypocalcaemic tetany''' due to a reduced ability to absorb the fat soluble [[Vitamin D|vitamin D]].
*'''Hypocalcaemic tetany''' due to a reduced ability to absorb the fat soluble vitamin D.
====Other Tests====
====Other Tests====
'''Measurement of faecal alpha1-protease inhibitor''' - This marker has a similar molecular weight to albumin and it is lost into the GI tract in PLE. Its concentration can therefore be measured in faeces as it is not degraded by GI enzymes. (Faecal samples must be frozen on collection before submission to a laboratory in the USA.)
'''Administration of 51-Chromium labelled albumin''' - A radioactive marker (51-Chromium) is attached to recombinant albumin molecules before injection into animal. Faecal samples are collected to determine whether the labelled albumin is being lost into the GI tract. Although this test represents the 'gold standard' test, it is available only at a limited number of referral institutes.
===Diagnostic Imaging===
===Diagnostic Imaging===
====Radiography====
====Radiography====
The results of '''abdominal radiographs''' are usually unremarkable but discrete mass lesions or ascites may be evident. '''Thoracic radiographs''' may show the presence of [[Effusions|pleural effusion]], metastatic neoplasia or evidence of [[Systemic Mycoses #Histoplasmosis|histoplasmosis]]).
The results of '''abdominal radiographs''' are usually unremarkable but discrete mass lesions or ascites may be evident. '''Thoracic radiographs''' may show the presence of [[Effusions|pleural effusion]], metastatic neoplasia or evidence of [[Histoplasmosis|histoplasmosis]]).
====Ultrasonography====
====Ultrasonography====
This may reveal:
#Changes to intestinal wall structure, including:
**Thickening without loss of normal layers (as with inflammatory bowel disease)
**Thickening with loss of layers (as with infiltrative intestinal neoplasia)
**'Tiger stripes', an unreliable indicator of lymphangiectasia
#Ascites or pleural effusion
*Mesenteric lymphadenopathy
===Histopathology===
===Histopathology===
'''Endoscopy''' can be used to visualise the proximal intestinal luminal surface and to obtain grab biopsies. Surgical biopsies may be obtained for definitive diagnosis of lymphoma and [[Lymphangiectasia#Description|secondary lymphangiectasia]]. A small fatty meal could be given the night before biopsy to increase the chance of diagnosing [[Lymphangiectasia|lymphangiectasia]].
'''Endoscopy''' can be used to visualise the proximal intestinal luminal surface and to obtain grab biopsies. Surgical biopsies may be obtained for definitive diagnosis of lymphoma and [[Lymphangiectasia#Description|secondary lymphangiectasia]]. A small fatty meal could be given the night before biopsy to increase the chance of diagnosing [[Lymphangiectasia|lymphangiectasia]].
Care should be taken with this procedure as animals with PLE have a greater risk of surgical wound dehiscence with the subsequent development of peritonitis.
Care should be taken with this procedure as animals with PLE have a greater risk of surgical wound dehiscence with the subsequent development of [[Peritonitis - Cats and Dogs|peritonitis]].
Lesions that may be observed on histopathological analysis of biopsy samples include:
Lesions that may be observed on histopathological analysis of biopsy samples include: signs of inflammatory bowel disease, dilated lymphatics and lipogranulomatous lymphangitis (especially in Soft-coated Wheaten terriers).
PLE may also be associated with protein losing nephropathy (PLN). PLN may be a chronic sequelae to the PLE. It follows immune complex deposition in the glomerulus, causing glomerulonephritis or glomerulosclerosis. PLN causes hypoalbuminaemia and hypercholesterolaemia.
Similar PLN and PLE lesions are seen in young Besenjis with immunoproliferative enteropathy and glomerulosclerosis.
==Treatment==
==Treatment==
Treatment of the underlying cause of disease should be initiated, if possible. In the case of severe respiratory embarrassment, treatment should be directed at draining any pleural effusion and providing support in case of a pulmonary thromboembolus.
Treatment of the underlying cause of disease should be initiated, if possible. In the case of severe respiratory embarrassment, treatment should be directed at draining any pleural effusion and providing support in case of a pulmonary [[Thromboembolism|thromboembolus]].
===Plasma transfusion===
This may be used to increase plasma volume but, as much of the albumin is lost into the gut, there may be a disappointing increase in serum albumin concentration after transfusion. Large [[Colloids|colloids]] (such as hetastarch) may also be administered to try to maintain plasma oncotic pressure.
This may be used to increase plasma volume but, as much of the albumin is lost into the gut, there may be a disappointing increase in serum albumin concentration after transfusion. Large [[Colloids|colloids]] (such as hetastarch) may also be administered to try to maintain plasma oncotic pressure.
===[[The Effects of Diuretics on the Kidneys - Anatomy & Physiology|Diuretics]]===
These may be used to reduce any ascites or pleural effusion and it has been suggested that [[Heart Failure, Treatment#C. Pharmacological |spironolactone]] may be more effective than [[Heart Failure, Treatment#C. Pharmacological|frusemide]] for this purpose.
These may be used to reduce any ascites or pleural effusion and it has been suggested that [[Heart Failure, Treatment#C. Pharmacological |spironolactone]] may be more effective than [[Heart Failure, Treatment#C. Pharmacological|frusemide]] for this purpose.
===Antithrombotic therapy===
Treatment may be initiated with low dose aspirin to prevent the development of thrombo-embolism.
Treatment may be initiated with low dose aspirin to prevent the development of thrombo-embolism.
===Dietary Supplementation with Calcium===
Calcium carbonate may be added to the diet if a low serum concentration of ionised calcium is documented.
Calcium carbonate may be added to the diet if a low serum concentration of ionised calcium is documented.
*Nelson, R.W. and Couto, C.G. (2009) '''Small Animal Internal Medicine (Fourth Edition)''' ''Mosby Elsevier''.
*Nelson, R.W. and Couto, C.G. (2009) '''Small Animal Internal Medicine (Fourth Edition)''' ''Mosby Elsevier''.
*Willard, M. (2005) '''Protein-Losing Enteropathy in Dogs and Cats''' ''30th World Congress of the WSAVA''.
*Willard, M. (2005) '''Protein-Losing Enteropathy in Dogs and Cats''' ''30th World Congress of the WSAVA''.
[[Category:Intestine_-_Inflammatory_Pathology]]
[[Category:Intestine_-_Inflammatory_Pathology]]
[[Category:To_Do_-_James]]
[[Category:To_Do_-_James]]
[[Category:Cat]][[Category:Dog]][[Category:Alimentary_Disorders]]
[[Category:Cat]][[Category:Dog]][[Category:Alimentary_Disorders]]
[[Category:To_Do_-_Review]]
[[Category:Expert_-_Review]]