Protein Losing Enteropathy

Signalment

Breed predisposition:

• Basenji
• Lundehund
• Soft-Coated Wheaten Terrier
• Yorkshire Terrier
• Shar Pei

Description

Protein-losing enteropathy (PLE) can result from any intestinal disease which produces sufficienct inflammation, congestion or bleeding. This causes protein to leak into the intestines, which exceeds the gut lumen protein synthesis. Hence, there are numerous causes of PLE, for example lymphangiectasia, infectious, structural, neoplasia, inflammation, endoparasites and gastrointestinal haemorrhage.

The major causes of PLE in adult dogs are inflammatory bowel disease (IBD), alimentary tract lymphoma, fungal infections (e.g. histoplasmosis). Other causes include ulcerations or erosions, severe disease of intestinal crypts and parasites. The most common causes in very young dogs are hookworms and chronic intussusception. Chronic intussusception results from acute enteritis which had not resolved completely, with some clinical improvement but continuation of diarrhoea. PLE is less common in cats than dogs, and most often caused by alimentary tract lymphoma and IBD. Cats almost never suffer from lymphangiectasia, and rarely have severe parasitic infection severe enough to cause PLE. Non-intestinal diseases which can be associated with PLE include congestive heart failure, caval obstruction and portal hypertension. However, these animals usually present with ascites rather than diarrhoea.

Diagnosis

Clinical Signs

• Weight loss (predominant feature)
• Vomiting and diarrhoea ± melena
• Oedema, ascites and pleural effusion
• Thickened intestines
• Thromboembolic disease if procoagulants predominant due to loss of anticoagulant

Laboratory Tests

Haematology

• Panhypoproteinaemia
  • Hepatic insufficiency and protein-losing nephropathy should also be pursued in hypoalbuminaemia.
• Lymphopaenia

Biochemistry

• Hypocholesterolaemia
• Hypocalcaemia

Other Tests

• Measurement of faecal loss alpha1-protease inhibitor

Diagnostic Imaging

Radiography

• Abdominal radigraps are usually unremarkable.
• Thoracic radiographs may show pleural effusion, metastatic neoplasia or eveidence of histoplasmosis.

Ultrasonography

• This may reveal thickening of intestines, mesenteric lymphadenopathy or abdominal effusion.

Histopathology

• Endoscopically guided multiple biopsies are useful. However, surgical biopsy may be required for a definitive diagnosis of lymphoma and secondary lymphangiectasia. A small fatty meal could be given the night before biopsy to increase the chance of diagnosing lymphangiectasia.

Treatment

Plasma transfusion

• This may be used to increase plasma volume perioperatively. However, much of the albumin is lost in the gut and a substantial amount does not remain in the intravascular compartment. Therefore, plasma transfusion is unable to increase the serum albumin level by much.
• Administration of colloid may be more suitable if it is necessary to increase the plasma oncotic pressure.

Diuretics

• This can be used to reduce ascites
• Spironolactone 1-2 mg/kg PO BID may be more effective than frusemide.

References

• Ettinger, S.J. and Feldman, E. C. (2000) Textbook of Veterinary Internal Medicine Diseases of the Dog and Cat Volume 2 (Fifth Edition) W.B. Saunders Company.
• Hall, E.J, Simpson, J.W. and Williams, D.A. (2005) BSAVA Manual of Canine and Feline Gastroenterology (2nd Edition) BSAVA
• Nelson, R.W. and Couto, C.G. (2009) Small Animal Internal Medicine (Fourth Edition) Mosby Elsevier.
• Willard, M. Protein-Losing Enteropathy in Dogs and Cats 30th World Congress of the WSAVA