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.

Prognosis

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.