Inflammatory matory Bowel Disease

[Rita and Fazzy]

Hi all....after a scare of bloat without torsion in May, my7 year old labradoodle Fazzy was diagnosed with IBD via biopsy.  He was doing OK once he got back to eating again until I thought it might be a good idea to switch to raw...didn't go well.  Switched him back to what he was on prior, Canidae kibble, variety of canned "flavors" as well as chicken breast, turkey breast, low fat hamburger...just depending on what we had on hand and cooked for the dogs.  I've never been able to get his stools back to normal and consistently solid and in the past week its just been yucky. He went to the vet yesterday and per their suggestion, we carried home a bag of Purina HA both dry and canned.  He ate a few bites yesterday but wants none of it today.  Over the past couple of weeks he has become less and less into eating, needing plenty of encouragement and hand feeding.  Vet also sent us home with Cerenia, metronidazole and Diagel.  Waiting for results of stool sample.  I really don't want to deal with the rx diet, but we also need to get his gut back to feeling better.  A couple of friends are pushing me to see a holistic vet, which I'm not opposed to, it's just expensive.  I hate that I have to even throw that word out there, but seeing a holistic is not out of the question.  Jolene suggested I reach out to Karen for some words of wisdom/suggestions ..and I know she'll see this.

Any suggestions, feedback etc would be great!!

Rita and Fazzy 

[Karen, Jasper and Jackdoodle]

Rita, you need to make an appointment with a veterinary internal medicine specialist TODAY. Inflammatory Bowel Disease is a serious auto-immune disease which requires immunosuppressant drugs in 80% of cases. I cannot believe that any vet would diagnose IBD and then not give you pages and pages of detailed instructions for meds & diet plus put the dog on some type of immunosuppressant. Just the fact that they didn't even explain the disease to you is shocking, and from your description of what you have tried feeding Fazzy, I know they didn;t. 
A holistic vet isn't going to help either. You need an IMS. 
You cannot manage this with food alone, although the HA food is just about the only thing your vet has done that makes any sense. IBD dogs need very restricted diets, immunosupprressants at least part of the time, probiotics ALL the time, other supplements, and B12 shots on a regular basis.

Please tell me that your vet at least gave him a B12 shot? 

[Karen, Jasper and Jackdoodle]

Oh, and whatever else you do, do not give him raw food!!!! 

[Rita and Fazzy]

Hi Karen...

When he bloated it was late at night and we took him into the local emergency hospital, he was there 4 nights. At the time of discharge they said we could see our vet or their internal med vet, was up to us. We didn't even get the biopsy results back until after discharge, and that was like 3 days later. We had taken him back in because he wasn't eating, lethargic...and the ER vet told us that the biopsy showed "consistent with IBD'. That night, all they did was x-ray to make sure there was no blockage and sent him home with some meds, if I recall correctly. When I connected with our vet after she reviewed the notes from that inpt stay, she said that if he wasn't vomiting or having diarrhea, which he wasn't, then just monitor.
No B12 injection, as a matter of fact I asked about that yesterday and she said that they would need to run a blood test checking to see where his level was.
Yeah, no more raw, trust me.

[Karen, Jasper and Jackdoodle]

I don't understand. WHY did they do a biopsy and how? Was it via endsoscopy, colonoscopy, or surgery? They don't typically do a biopsy for bloat, they do gastropexy surgery. Maybe they did a biopsy during surgery?
Biopsy results for IBD are pages and pages long, they are very detailed and they tell you exactly what kinds of inflammatory cells were found in what part of the GI tract as well as the condition of the intestinal lumen. And all of his blood chemistry readings. Then they tell you, "he has eosinophilic IBD" or lymphoplasmacytic IBD, or whatever, and the colon is worst, or the small intestine, etc. You have to know what kind and where to treat it effectively. 
And they would never ever in a million years send him home after an IBD diagnosis without meds. Follow up with you vet or the internist, yes, but they still start treating. An inflammatory condition means there is an immune response causing that inflammation, and that doesn;t ever go away by itself. And then for your vet to just say monitor...something is very wrong here.

What were the meds they sent you home with three nights later after the Xrays? 
A GI blood panel is part and parcel of the initial diagnosis. It is shocking that wasn't done at the time of the biopsy. That would have told you what his B12 levels were, and with IBD they are almost always low.

Did you have that blood work run yesterday?
Your vet could have given him a shot regardless, B12 is water soluble and harmless and it is nearly impossible to get too much. It would not have hurt him no matter what his levels were. 
But when you are dealing with IBD, those B12 levels are markers, and you need to know them and monitor them. 

IBD is a big deal. It's incurable, but it can be managed with the right combination of drugs and diet. It is fatal in 20% of cases no matter what you do. 20% of lucky IBD dogs can be managed with diet alone after the inflammation is brought into remission with drugs. Has he been given prednisone or another immunosuppressant drug at any point at all since diagnosis? 
You really need to see an IMS, find out what exactly the biopsy showed, get him on a proper treatment plan which includes immunosuppressant drugs, supplements, probiotics, and diet, and find out his B12 and folate status and get those B12 injections started. 

[Rita and Fazzy]

So, they did the biopsies when they went in to do the gastropexy.  Pexy on 5/21 along with biopsies.  Discharged 5/23.  I'm reading the docs given...discharge instructions :

Activity restrictions 

Incision care 

Diet :  feed small frequent meals.  Feed bland diet for the next few days such as chicken /white rice or Hills I/D.

Eliminations...could be a few days before he poops, etc...

Medications:  codeine, gabapentin, Cerenia, Metoclopramide, erythromycin 

Follow up...sutures to be removed in 10-14 days.

Additional follow up...biopsies have been sent out.  Results in 5-7 days and at that time we will discuss additional treatment recommendations at that time.

We took him back to ER two days later as they told us to watch for inappetance, lethargy, etc as there is a small chance of leakage at the biopsy site....he wasn't eating and seemed lethargic...so back we went.  It was the ER doc that told us that the biopsies had come back as consistent with IBD.  She suggested an ultrasound (not an xray like I originally mentioned) to check for obstruction.  Also did a cortisol test.  I'm reading the write up regarding the dx of IBD.  It says that he likely will need to be treated with steroids but to give Fazz time to heal from surgey.  It goes on to explain what IBD is, diet...hydrolyzed diets, novel protein diets.  Medications used include prednisone, budesonide.

It wraps up with  "We have discussed continuing to encourage Tralfaz's appetite in the short term with various bland diets.  Once he is eating consistently he should be transistoned to a hydrolyzed diet.

Med given that evening was mirtazapine.

Followed up with our vet after she was faxed all the records.  She said that if he wasn't having any issues in regard to vomiting or diarrhea on his normal diet, then continue that and let her know if something changes.

So, here we are today with a boy who isn't feeling great.  Wants nothing to do with the HA food.  I did call the specialty offices and internal med isn't in until tomorrow morning so I'll call back then.

When I look at the labs...they did  "ProCyte" "Catalyst" "VetStat"  I don't know if those are particular panels or what.  I'm not seeing much that would look like folate, B12, etc.

We did not have the B12 blood work done as it is apparently a fasting blood test and she certainly didn't present it as tho it really should be done.  More of a "well, we could, but it's pretty spendy".  

I'm feeling a little stupid, like maybe I should have known more, etc.   I can certainly upload the blood work results if you want to see them.  The ER hospital never followed up in regard to seeing the IMS or the urgency.

The B12 blood test is apparently $330, does that sound right?  I know all of this is expensive, fortunately we do have insurance.

Oh, and we never received written biopsy results, our vet called the hospital and had them faxed over to her.  Biopsy was done because there was slightly thickened duodenum and section of jejunum.  The biopsies were taken from duodenum, jejunum and mesenteric lymph node....reading from the surgery notes.

[Karen, Jasper and Jackdoodle]

I never paid more than $200 for the GI panel (B12 blood work), but I haven't had one done in probably 5 years. I'm also in a very expensive area, though. $330 sounds high to me. 
Honestly, it sounds like you vet dropped the ball with initiating the IBD treatment which was supposed to start after Fazzy healed from the surgery. No prednisone, no hydrolyzed diet, nothing but monitoring.
IBD is a disease that can't just be monitored. 
Yes, it's very expensive. I am glad you have insurance. 
Please contact the IMS as soon as possible. 

[Rita and Fazzy]

Looking at the invoice, looks like the blood work is CBC/Chem 15/ Electrolytes/Diff

Thank you....we'll be talking to them tomorrow morning to make an appointment.   In the meantime, how do we get this boy to eat something?

[Karen, Jasper and Jackdoodle]

This is the hardest part of IBD. The diet is very restricted. It's either one single novel protein (one the dog has never eaten before) or a hydrolyzed protein diet, which is what the Purina HA is. (Personally, I like Royal Canin HP better. Still not a great food, but better than Purina.)

In hydrolyzed protein diets, the protein molecules are so small that the body can't recognize them and therefore won't react with an immune response.
And you can't start a novel protein diet while there is inflammation present, because the nature of IBD is that unless you suppress the inflammatory response, the immune system is going to react eventually to the new protein too, so to start it while there is inflammation present is to basically waste a novel protein...and there aren't that many of them.

Mirtazapine is used to help stimulate appetite in IBD dogs. Your vet should have given you that. 
Treats are limited to the same single protein as the diet, or something like raw carrots that is unlikely to trigger an immune response. I think the RX food companies do make treats with hydrolyzed protein, but I'm not sure. Some people bake small "slices" of the canned food to resemble dog treats. 
Chews are limited to things like inedible Nylabones, which are hypoallergenic. Jackdoodle was able to have elk antlers, but not at first. 
It's hard. 
The only thing I can suggest is to mix a good amount of the canned food with the kibble, and add a little bit of hot water to give it some aroma appeal. 

[Rita and Fazzy]

I do have to tell you....I have taken some of your recommendations in the past, such as Proviable.  I told our vet that we had that but they insisted that their Entero Flora Pro by Vetri Science is better.  Do you have any thoughts on that one?

We are 24 hours now without eating, I just gave him Cerenia a bit ago, hopefully that'll kick in and he'll eat some.  If not, call to the vet for some mertazapin...and I have no guess when the first available appointment might be for the  IMS, but we'll find out tomorrow morning 

[Karen, Jasper and Jackdoodle]

The Entero Flora Pro is a good probiotic. It may be better than Proviable, it does have more CFUs. I typically suggest Proviable because it's reasonably priced and widely available, but it's not the only good probiotic out there. What you don't want is what many vets carry, Purina's Fortiflora. Iams Prostora is also not recommended.

Cerenia is given for nausea, I hope it helps.

[Rita and Fazzy]

I've read your thoughts on FortiFlora many times  ;-)

He's had cerenia on board note for over an hour and it's a big no go for eating.  

[Karen, Jasper and Jackdoodle]

Yeah, unless he wasn't eating because he felt nauseated, the Cerenia wouldn't do much.