PLE/Lymphangiectasia New

[tripsplus6]

Our yorkie Rosie is almost 12 years old and became very ill rather suddenly about 2 weeks ago. She has always been very healthy, voracious eater, no vomiting or diarrhea history, wt. 5-6 lbs. But over time, probably last 2 or 3 years, she has had a big tummy, vet said she's healthy maybe test for worms, all negative. She started coughing a few weeks ago, and her breathing seemed noisy sometimes and labored, as if pressure from distended tummy. We took her in for cough and evaluation, check tummy, did chest xr showing some fluid, put her on Clavamox, lasix, and Temaril-P. Cough went away in 2 or 3 days, and vet said to stop the Temaril P and then get bloodwork in a week. Cough came back during this time, but otherwise appetite good, etc. Got results of BW on April 12, low albumin (2.2), liver and kidney ok. Referred us to IM Specialist, 1st appt 2 1/2 weeks away, add bile acid and urine, both normal. Two days later much worse, stopped eating (drinking well), weak and wobbly, then developed diarrhea. Took her to Specialty Hosp (thru ER) an hr away in Akron Thurs night. Chest ok but ultrasound removal of 92cc clear fluid from abdomen. GI tract PLE, sent home on Metronidazole and Proviable Forte Kit. Asked about Prednisone, said to ask home Vet. Home vet said to also continue Lasix and able to get appt with IM specialist nearby on Wednesday. But no prednisone, let IM decide. Rosie is much better since fluid tap, great appetite, no diarrhea, some coughing though. But up and around ok. I'm feeding her boiled white potato, egg whites, carrots, bit of fat free yogurt. She loves it all and gobbles it down several times a day. I hope she stays stable enough to wait for IM appt on Wed. I thought if she had some prednisone to help reduce inflammation, her extremely low fat high protein diet would be much more effective in healing her intestines. Maybe they want no prednisone if doing biopsies, but does she need biopsies? Cant we use diet and meds and either defer bx till better or maybe always manage medically without bx at her age? Wt. is stable.

[Bluebells]

I don’t have any experience with this, but I think your “does she need biopsies?” question is an appropriate one to ask the vet before one is performed. What, exactly, is the vet looking for by doing a biopsy and why is that suspected?

I understand that the fluid in your girl’s abdomen is abnormal, and one cause could be cancer, but there are other possible causes. The only abnormal test result I see is the one, slightly low, albumin test, but that could have been the result of several days of gastrointestinal upset.

If this were my dog, and she seemed to be feeling better now, I would proceed cautiously with invasive testing until/unless the vet can give you sound justification for that testing.

[tripsplus6]

Thank you Bluebells. I think they like to have a confirmed diagnosis of which condition in the intestine is causing the protein loss and symptoms. I used the term lymphangiectasia bc it can be more common in yorkies, but I haven't been given that definitive diagnosis. Perhaps the IM dr can tell more if he does an ultrasound, or maybe there will be results from the abdominal fluid analysis that will give more info. This could be from inflammatory bowel disease or even lymphoma. They often like to do endoscopy even if they don't get biopsies. She just doesn't seem strong enough yet for anesthesia so I wondered if treatment with something like prednisone and the strict low fat diet I am cooking for her will get her stronger before that kind of testing. I will definitely discuss it with the IM on Wed. Until then she is still on Metronidazole, Furosemide, and Proviable Forte sprinkles (finished with paste). Gave her a Temaril P last night and cough is gone. ??

[ladyjane]

Sorry I didn't see this sooner but not sure I could do a lot other than tell you that internal med is definitely the way to go. I see you have an appointment today....I hope you come away with answers. As to the prednisone, they won't give that if they are thinking biopsies are in order. You do not have to agree to a scope/biopsies, but yes, it will give them a diagnosis so they can have a solid treatment plan. I am sure if they think it is too risky, they will not do it. I don't think they put them under totally for a scope as I have had them done as an outpatient. Keep in mind that they can treat with prednisone but if they are guessing and she has IBD she may need a diet with novel protein. It is always better to know what you are dealing with. Just ask a lot of questions!

Diet....I hope they advise you to either go with an RX food (something like Royal Canin gastrointestinal low fat) or home cooking but only under the guidance of a veterinary nutritionist. There actually is a web site run by a vet nutritionist that will give you a free diet but you do have to purchase the necessary supplements. www.balanceit.com
But, again, if she has IBD the RC may not be the right diet.

I home cooked for 6 years for my lymphangectasia/ibd pup, Cookie. My Kiche now has lymphangectasia and he is on the RC food mentioned above. His albumin stays at 2.2 on prednisone....since it has been that way for one year and his weight is stable, they consider him stable. I am sharing this to say that RX food is good.
Just for reference: my Cookie was 0.9 when diagnosed...so while 2.2 is indeed low, it isn't as scary (at least not to me...but just a lay person)

Not sure why the lasix ... the fluid is probably from the protein loss but of course I am just guessing. The cough may be from another reason. I think you will have a better idea today after seeing IMED.

I hope all goes well today. I am sending you a message now......

[ladyjane]

Looking for an update....hope all went well at the specialist today.

[tripsplus6]

We took Rosie to the Internal Med Vet yesterday and I think it went fairly well. He felt that all her labs looked good except for the albumin, and the analysis of the fluid removed from her abdomen was just as expected with PLE, and there are no indications of any cancer with her. He feels that when dogs have congenital lymphangiectasia, that it tends to show up earlier in life, maybe around 3 yrs of age or so. Since Rosie is almost 12, he feels it is more likely that she has lymphangiectasia from chronic IBD over the last few years. I'm not sure if that is the standard school of thought, but whatever, he felt treatment with Prednisolone would address the inflammation and help the high protein diet to be utilized in raising her albumin level. He had some concerns about her being so tiny and frail for anesthesia and especially for healing from any biopsies, so the most he would be comfortable doing now would be just endoscopy but it would still be with anesthesia. He felt that it would be ok to just go ahead with treating therapeutically now with meds and diet, and see how she does especially since her appetite is excellent now that the abd fluid has reduced the pressure. There was some concern of lipemia, cholesterol was normal tho but he plans to draw fasting triglycerides next week. He was very pleased with the home cooked diet I'm doing high protein and almost no fat so we will stick with that. I plan to check out the vet nutritionist site as well for more balance once this acute phase is improved, maybe a couple of weeks? So, she is just on Prednisolone 2.5mg/day. I use the Proviable Forte sprinkles on her food once/day. I guess it's for intestinal health and probiotic. He didn't feel she needed to be on the furosemide(lasix) or metronidozole (flagyl), so I guess it's pretty much prednisone and diet. I hope that's aggressive enough. Should I try adding some Spirulina for more protein too? She has been eating egg whites and some whitefish (cod) for most of her protein. Maybe fat free cottage cheese and more fat free yogurt? Mostly cooking white potatoes for calories and fill her up.

[ladyjane]

Originally Posted by tripsplus6

We took Rosie to the Internal Med Vet yesterday and I think it went fairly well. He felt that all her labs looked good except for the albumin, and the analysis of the fluid removed from her abdomen was just as expected with PLE, and there are no indications of any cancer with her. He feels that when dogs have congenital lymphangiectasia, that it tends to show up earlier in life, maybe around 3 yrs of age or so. Since Rosie is almost 12, he feels it is more likely that she has lymphangiectasia from chronic IBD over the last few years. I'm not sure if that is the standard school of thought, but whatever, he felt treatment with Prednisolone would address the inflammation and help the high protein diet to be utilized in raising her albumin level. He had some concerns about her being so tiny and frail for anesthesia and especially for healing from any biopsies, so the most he would be comfortable doing now would be just endoscopy but it would still be with anesthesia. He felt that it would be ok to just go ahead with treating therapeutically now with meds and diet, and see how she does especially since her appetite is excellent now that the abd fluid has reduced the pressure. There was some concern of lipemia, cholesterol was normal tho but he plans to draw fasting triglycerides next week. He was very pleased with the home cooked diet I'm doing high protein and almost no fat so we will stick with that. I plan to check out the vet nutritionist site as well for more balance once this acute phase is improved, maybe a couple of weeks? So, she is just on Prednisolone 2.5mg/day. I use the Proviable Forte sprinkles on her food once/day. I guess it's for intestinal health and probiotic. He didn't feel she needed to be on the furosemide(lasix) or metronidozole (flagyl), so I guess it's pretty much prednisone and diet. I hope that's aggressive enough. Should I try adding some Spirulina for more protein too? She has been eating egg whites and some whitefish (cod) for most of her protein. Maybe fat free cottage cheese and more fat free yogurt? Mostly cooking white potatoes for calories and fill her up.

Happy to hear the vet is not overly concerned at this point.

No advice here from this YTer on a diet as it is SO important in PLE. I would never guess on a diet for a dog with lymphangectasia. It is not a simple thing. Additionally, supplements are so important. I am actually surprised any vet would recommend a diet without them.

From https://www.marvistavet.com/intestin...ted%20patients).

Nutritional management of PLE is a bit tricky. The diet must be especially digestible and high in protein (20-25% protein on a dry matter basis) so as to replace all the protein being lost through the leaky GI tract. Further, the diet should be no more than 15% fat on a dry matter basis (lower for more severely affected patients). Reading a diet label shows percentages on an "as fed" basis, so to compare diets, it is necessary to convert values to a dry matter basis through knowing the moisture content. To see how this is done click here. There are prescription diets available for diseases like this one where fat restriction is crucial. Non-prescription diets are unlikely to meet the above criteria but if you know how to read the food label properly you may be able to find one. Injectable vitamin supplements are likely to be needed.



Thanks for the update!

[ladyjane]

https://todaysveterinarypractice.com...thies-in-dogs/


Quote from the above link:

While there is no inherent benefit to feeding a home-prepared diet in most cases, some people may prefer to feed such a diet. Most recipes found online or in books do not provide complete and balanced nutrition;15 thus, a board-certified veterinary nutritionist should be consulted if an owner wants to feed a home-prepared diet (Table 5). The importance of consulting with a veterinary nutritionist cannot be overemphasized.

[tripsplus6]

I totally agree about needing expert nutritional management and that Rosie needs supplements on such a strict diet that I am doing. I called the IM specialist office today and talked to the tech, she will check with dr but I havent heard back. I think their thought is that this strict home cooked diet will only be for a couple of weeks while the Prednisolone and ultra low fat gets the inflammation under control and she can absorb the protein at the same time. She goes back on Wed and will have bloodwork then so he is probably planning to address all this then. I've explained my concern with both vets regarding feeding so much protein (since she eats well, it's easy to do but I fear it is too much but they said its not a problem.). I feed her the white potatoes too for carbs and filling her up and keeping her weight up. I just don't see how she can heal and get healthier without more nutrients as well. She gets the Proviable sprinkles (pre and pro biotics) but that is what the ER gave us when they did the abdominal tap, it's not from the IM specialist, but I told him she is on that. I am being so careful and so strict about everything in her diet, she eats several small meals per day, but I would hate to have things go badly simply because she needs something as basic as a vitamin added.

[ladyjane]

Originally Posted by tripsplus6

I totally agree about needing expert nutritional management and that Rosie needs supplements on such a strict diet that I am doing. I called the IM specialist office today and talked to the tech, she will check with dr but I havent heard back. I think their thought is that this strict home cooked diet will only be for a couple of weeks while the Prednisolone and ultra low fat gets the inflammation under control and she can absorb the protein at the same time. She goes back on Wed and will have bloodwork then so he is probably planning to address all this then. I've explained my concern with both vets regarding feeding so much protein (since she eats well, it's easy to do but I fear it is too much but they said its not a problem.). I feed her the white potatoes too for carbs and filling her up and keeping her weight up. I just don't see how she can heal and get healthier without more nutrients as well. She gets the Proviable sprinkles (pre and pro biotics) but that is what the ER gave us when they did the abdominal tap, it's not from the IM specialist, but I told him she is on that. I am being so careful and so strict about everything in her diet, she eats several small meals per day, but I would hate to have things go badly simply because she needs something as basic as a vitamin added.

Honestly, if it were me, I would either do a consult with a vet nutritionist or go with prescription food.
My Kiche is doing well on Royal Canin Gastro Low fat. (I think I posted that the other day).
It is more than just supplements...you really need to know calorie content and also the proper balance of carbs/proteins. It just isn't good to guess especially with a dog with PLE. I did not give my Cookie large amounts of protein. It was actually pretty small. The big issue is fat content. They do need some fat but very tiny amount.
Hope the appt goes well this week!

[tripsplus6]

Rosie's bloodwork was 2 weeks ago tomorrow. I thought it would be a checkup but just bloodwork. It was just Chem and Metabolic Profile, basic

[tripsplus6]

Rosie had bloodwork 2 weeks ago tomorrow, thought it would be a checkup but no. It was just Blood Chemistry and Metabolic Profile, very basic bloodwork, and yet I still have not been able to have a conversation with the Vet (Int Med Specialist). I think he must have gone on vacation and the secretary finally answered my calls last week. I also had to send emails and a fax because I wasn't getting response. And when we do take her in, they are still be very strict about Covid so we never see the Vet. We have to wait in the car and the girl comes and gets the dog and then brings her out when done. The Vet then calls us in the car on our cell phone. I asked the secretary to email me the Blood work results. Rosie's Protein had gone up from 4 to 5.2, and her Albumin had increased from 2.2 to 2.6. She is eating and drinking and maintaining her weight, normal poops. The secretary said he said to continue with her diet of white potatoes, egg whites, whitefish, Proviable pre and probiotics, and the same dose of Prednisolone of 2.5 mg per day. He said to just add a multivitamin and half a Tums. Yogurt or cottage cheese if we want. Recheck labwork in 2 months. This all sounds very casual to me, but I have not been able to speak with him since her first visit a month ago. The fluid removed from her abdomen relieved the pressure back then, but I'm wondering when the big belly goes down, or does it? She has had the big distended belly for about 3 years so maybe that will be her normal? If labs are improving and she feels good, is that ok? But why doesn't he examine her or talk to us? The secretary's email said to get a multivitamin from our regular vet, but I called them and they don't carry them. I ordered NutriVet online. Anyway, is that bloodwork a good improvement? It seems to be approaching the low end or normal range for her albumin, so I'm hoping her intestines etc are healing. Not sure how that is determined though.

[ladyjane]

I have had four pups with PLE....Cookie is the best one for me to share in terms of treatment and it being documented here. What you are being advised diet wise is not something I have ever done or been advised to do. Not saying it is wrong...just isn't what I have done or would do. As mentioned above I sought out the counsel of vet nutritionists. Cookie lived a long life with PLE and what got her in the end was lymphoma. I posted that information above...the one link does emphasize the importance of a very balanced diet for this condition!

When Cookie had fluid unbalance, she was given hetastarch. I don't know why your Rosie's abdomen is swollen, but you might ask them to explain.
It is great that her numbers are up and yes, they do usually start backing off on rechecks....at first that was scary to me. I was ready to check all the time...I was so afraid she would go bad so believe me I get it!

Perhaps Cookie's story will help you.
https://www.yorkietalk.com/forums/si...ia-update.html