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Peer Reviewed Symptomatic Management of Primary

Symptomatic Management of Primary Acute Gastroenteritis

Yuri Lawrence, DVM, MA, MS, Diplomate ACVIM (Small Animal Internal ), and Jonathan Lidbury, BVMS, MRCVS, Diplomate ACVIM (Small Animal Internal Medicine) & ECVIM (Companion Animal) Texas A&M University

Acute gastroenteritis is a term used to describe a Table 1. characterized by the sudden onset of Selected Causes of Secondary Acute and/or caused by gastrointestinal Gastroenteritis mucosal . • Prototheca species Algal This diagnosis is seldom confirmed by Bacterial • species histopathologic evaluation; instead, it is based on • Clostridia species a consistent clinical presentation and exclusion of • • Neorickettsia helminthoeca other potential causes for the patient’s clinical signs. • species Mucosal inflammation is assumed, but not proven Drugs • to be present. Therefore, acute gastroenteropathy is • Cyclosporine perhaps a more appropriate name. • Glucocorticoids • Mycophenolate • Nonsteroidal anti-inflammatory drugs DIAGNOSTIC EVALUATION Acute gastroenteritis is among many potential Parasitic • Ancylostoma caninum • Ollulanus tricuspis causes of acute vomiting and diarrhea (Table 1). • Physaloptera species However, in many cases, the cause of primary acute • Strongyloides species gastroenteritis is not determined. Rapid resolution • Toxoascaris leonina of clinical signs often means that extensive diagnostic • Toxocara canis evaluation is unnecessary. Protozoal • parvum • species • Isospora canis No specific physical examination findings are Systemic • Bacterial • mucocele for acute gastroenteritis, and some • Gastric dilatation and dogs do not have any significant abnormalities. • Hepatic disease Findings consistent with acute gastroenteritis include • Hypoadrenocorticism • lethargy, pytalism, and abdominal discomfort. • It is particularly important to assess the patient’s • Renal disease hydration status and palpate the carefully, • checking for physical examination findings that • Septic • Splenic torsion would warrant further diagnostic evaluation (ie, abnormalities that suggest the problem is more • Chocolate • Lead significant than straightforward acute gastroenteritis) • Mushrooms (Table 2). Findings that indicate • Organophosphates include dry oral mucous membranes, prolonged • Xylitol • capillary refill time, and prolonged skin tent. Tachycardia, weak pulses, and cool extremities are Viral • Canine • Canine parvovirus consistent with . • Feline immunodeficiency • Feline virus Laboratory Analysis • Feline parvovirus (panleucopenia virus) Patients with a normal physical examination and

46 Today’s Veterinary Practice | November/December 2015 | tvpjournal.com SyMPTOMATIC MANAGEMENT OF PRIMARy ACUTE GASTROENTERITIS Peer Reviewed

mild clinical signs may not require laboratory testing on initial presentation. However, laboratory testing may be indicated to rule out extra-gastrointestinal causes of acute gastrointestinal signs, such as acute kidney , acute , and pancreatitis, and metabolic complications of acute gastroenteritis, such as and acid base abnormalities. When performed, laboratory testing should include a complete count, serum biochemical profi le, and urinalysis. Measurement of serum canine pancreas-specifi c lipase concentration may also be indicated to diagnose pancreatitis, and baseline serum cortisol concentration may be measured in order to exclude hypoadrenocorticism. Additional laboratory testing for infectious disease should be considered based on geographic location and FIGURE 1. Gastric nematode presumed to be signalment. For example, serology assists in diagnosis Physaloptera rara visualized during gastroscopy. of Salmon poisoning disease in the Pacifi c Northwest. The hemorrhage observed is associated with In dogs with diarrhea, fecal fl otation and direct smear gastric biopsy. examination should be performed to screen for primary or concurrent (Figure 1). In patients with clinical fi ndings (Table 2) or laboratory results that suggest a serious underlying cause, or those that do not respond to therapy, further diagnostic evaluation is indicated. Early identifi cation is especially important in patients requiring surgical intervention, such as those with an obstructive intestinal (Figure 2).

Imaging Abdominal ultrasonography and/or abdominal learn More radiography are strongly advised in patients Turn to page 77 to presenting with abdominal to screen for read the article, requiring surgical intervention. It is important to Endoscopic Foreign Body Retrieval. FIGURE 2. Fabric gastric foreign body visualized Table 2. during gastroscopy. Selected Clinical Findings That Indicate Further Diagnostic Evaluation in Dogs & remember that pancreas-specifi c lipase concentrations Cats with Acute Vomiting and/or Diarrhea can be increased in dogs and cats with gastrointestinal • foreign bodies. Therefore, it is essential to rule out • • Bradycardia gastrointestinal foreign bodies with abdominal • Chronic vomiting or diarrhea radiographs and, possibly, abdominal • before pancreatitis is diagnosed. If there is high • Hyperthermia or • Jaundice suspicion for a gastrointestinal foreign body that • Lack of current vaccinations may have been obscured by fl uid or gas, diagnostic • Lymphadenopathy imaging should be repeated. • Masses or organomegaly on abdominal palpation • • Polyuria/polydipsia THERAPEUTIC APPROACH • Tachycardia When acute gastroenteritis is the primary cause • Tachypnea, , or abnormal lung sounds • Weak pulses of vomiting and/or diarrhea, the symptomatic • Weakness treatments discussed in this article are appropriate • Weight loss for therapy. However, if gastroenteritis occurs

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secondary to an underlying disease, such as &

hypoadrenocorticism, it is essential to treat the Ondansetron and dolasetron are serotonin (5-HT3) primary condition in addition to providing antagonists with potent activity that are symptomatic and supportive therapy. commonly used off-label to control in dogs This article emphasizes symptomatic treatment of and cats. This class of drug blocks the chemoreceptor primary acute gastroenteritis rather than detailing trigger zone and vagal afferent pathways involved specific treatment of serious underlying diseases that in emesis. In our experience, these drugs are very may cause similar clinical signs. effective for control of vomiting in dogs and cats.

ANTIEMETIC DRUGS For acute gastroenteritis, antiemetic therapy is often Substance P is a neurotransmitter that binds to used for the initial 24 to 48 hours when vomiting is a neurokinin-1 (NK-1) receptors and can result in prominent clinical sign (Table 3). Benefits include: vomiting. Therefore, NK-1 receptor antagonists • Improved patient comfort are powerful effective at treating both • Decreased ongoing fluid and electrolyte losses peripheral and central causes of vomiting. • Earlier reintroduction of enteral nutrition Maropitant, a NK-1 receptor antagonist, is • Reduced risk of and esophageal currently the only licensed antiemetic for use in dogs stricture formation. and cats and, in our opinion, is very effective. This Take care not to mask ongoing disease with drug may also have an effect and, thus, is prolonged (ie, greater than 3 days) antiemetic widely used in patients with vomiting and abdominal therapy. In addition, to reduce the risk of pain, such as those with pancreatitis.1 The efficacy gastrointestinal perforation and avoid delay of of maropitant for the control of presumed nausea is surgical intervention by masking clinical signs of controversial as some studies have shown a benefit intestinal obstruction, do not administer antiemetic while others have not documented a benefit.2-6 or prokinetic drug therapy when a foreign body is While maropitant is not licensed for IV use, we suspected or confirmed. and other clinicians have administered it by this Several classes of antiemetic drugs are used in small route—at a dose of 1 mg/kg Q 24 H—without animal medicine. Occasionally, refractory cases require the apparent adverse effects. The manufacturer use of more than one of these drugs at the same time. recommends that after 5 days of continuous

Table 3. Medical Therapy for Vomiting Due to Acute Gastroenteritis DRUG DOGS CATS Antiemetics Ondansetron 0.1–1 mg/kg PO Q 12–24 H 0.1–1 mg/kg PO or IV Q 12–24 H Dolasetron 0.5–1 mg/kg IV Q 12 H 0.6 mg/kg IV Q 12 H Maropitant 1 mg/kg SC Q 24 H 1 mg/kg SC Q 24 H 2 mg/kg PO Q 24 H 2 mg/kg PO Q 24 H 1 mg/kg IV Q 24 Ha 1 mg/kg IV Q 24 Ha 0.2 mg/kg SC or PO Q 8 H 0.2–0.4 mg/kg PO or SC Q 6–8 H 1–2 mg/kg/H IV CRI 1–2 mg/kg/H IV CRI

Gastroprotectants Sucralfate 0.5–1 g PO Q 8–12 H (tablet or slurry)b 0.5 g PO Q 8–12 H (tablet or slurry)b Famotidine 1 mg/kg PO or IV Q 12 H 1 mg/kg PO or IV Q 12 H Omeprazole 1 mg/kg PO Q 12 H 1 mg/kg PO Q 12 H Pantoprazole 1 mg/kg IV Q 24 H 1 mg/kg IV Q 24 H Misoprostol 2–5 mcg/kg PO Q 8–12 H Not applicable a. Not a manufacturer recommended route of administration b. Potential reduced risk of emesis if administered as a slurry

48 Today’s Veterinary Practice | November/December 2015 | tvpjournal.com Symptomatic Management of Primary Acute Gastroenteritis Peer Reviewed

administration the drug should be discontinued for Famotidine & Ranitidine

24 hours to avoid drug accumulation; then treatment Famotidine and ranitidine are histamine-2 (H2)- can be restarted, if necessary. receptor antagonists that competitively inhibit histamine-induced acid secretion by the gastric Metoclopramide parietal cells. Antidopaminergic agents, such as metoclopramide, Famotidine is more effective at increasing have both central and peripheral antiemetic canine gastric pH compared with ranitidine, but effects and are used off-label in dogs and cats. ranitidine also has anticholinesterase activity. This Metoclopramide also stimulates the release of activity may result in some prokinetic action but in acetylcholine from postganglionic nerves in the studies was only as effective as a placebo at peripheral nervous system, which leads to increased increasing gastric pH in dogs and cats; thus, it is not 9,10 gastric contractions and increased gastroesophageal recommended for its acid-suppressing effects. sphincter tone. This promotility effect may also H2-receptor antagonists are less efficacious than contribute to its antiemetic properties. proton pump inhibitors (PPIs) in vivo, but the degree Metoclopramide can cause neurologic side effects, of inhibition necessary for therapeutic including excitement and restlessness. The short effect is unknown. H2-receptor antagonists may also 11,12 half-life of this drug necessitates frequent dosing. In have cytoprotective properties. our experience, it is most effective when delivered via an IV constant rate infusion but is not as Omeprazole & Pantoprazole Omeprazole and pantoprazole are PPIs that effective as maropitant, ondansetron, or dolasetron. irreversibly inhibit acid production by gastric parietal Metoclopramide may not have a direct central cells. This class of drug is more efficacious and antiemetic effect and is a less effective antiemetic has a longer duration of activity than H -receptor agent in cats than in dogs.7 For this reason, we 2 antagonists; it may also exert a cytoprotective effect seldom use it for this purpose in the former unless a by enhancing prostaglandin synthesis.9-11,13 prokinetic agent is also indicated. In dogs and cats, twice-daily dosing of omeprazole is more effective at reducing gastric Phenothiazines acid secretion than once-daily administration.9,10 Phenothiazines, such as chlorpromazine and Coadministration of famotidine and pantoprazole prochlorperazine, are potent centrally acting does not seem to be any more effective than therapy antidopaminergics that inhibit the vomiting center and with pantoprazole alone and, thus, there is no chemoreceptor trigger zone. This class of drug also has benefit in using a H2-receptor antagonist for the first antihistaminergic and anticholinergic properties.8 24 hours of therapy.14 They are not recommended in hypovolemic Because of this, PPIs are the preferred treatment patients due to potential for hypotension, and these for dogs and cats known or suspected to have drugs are not licensed for use in dogs and cats. esophageal or gastroduodenal ulceration.11,14 Phenothiazines can cause mild sedation and are no Anecdotally, some dogs and cats with acute longer commonly used due to the availability of other gastroenteritis, but no other findings that indicate effective antiemetic drugs. gastroduodenal ulceration, such as hematemesis or melena, appear to respond favorably to acid- GASTROPROTECTANTS suppressing drugs. However, use of these drugs has Sucralfate not proven beneficial in any studies in dogs and cats Sucralfate is a sulfated disaccharide that binds to with uncomplicated gastroenteritis; thus, they are not the acidic moieties of exposed collagen in damaged routinely recommended for brief episodes. mucosa, creating a protective barrier against further In humans, long-term use of PPIs has been acid damage. It also stimulates prostaglandin release associated with such side effects as cobalamin and cellular proliferation at sites of ulceration and deficiency, iron deficiency, hypomagnesemia, increases mucus production and bicarbonate secretion. increased susceptibility to , enteric Sucralfate is recommended only in cases of suspected , fractures, hypergastrinemia, and gastrointestinal erosion or ulceration, such as those that cancer.15 To our knowledge, other than present with hematemesis or melena. It can interfere hypergastrinemia, the side effects described above with absorption of other drugs, and is typically given at have not been reported in dogs and cats receiving least 2 hours before or after other medications. long-term treatment with PPIs.

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Misoprostol Misoprostol is a synthetic prostaglandin E1 that Table 4. acts on parietal cells to inhibit secretion of gastric Examples of Commercial for Dogs & Cats acid. Additionally, it has a cytoprotective effect by increasing secretion of mucus by gastric goblet cells, • FortiFlora (purina.com) • Prostora (iams.com) increasing gastric mucosal blood flow and increasing • Proviable (nutramaxlabs.com) turnover of gastric mucosal cells. • Sivoy (sivoy.net) PPIs and H2-receptor antagonists are thought to be more effective for treatment of gastrointestinal further study of these products is needed before ulcers, and misoprostol may cause vomiting, diarrhea, definitive recommendations can be made. and abdominal pain. Use of misoprostol is, therefore, The efficacy of some probiotics for treatment of not advised in dogs with acute gastroenteritis chronic diarrhea in dogs and cats has been evaluated unless gastroduodenal ulceration associated with but, to our knowledge, there have only been 2 studies nonsteroidal anti-inflammatory drug (NSAID) use is evaluating the efficacy of probiotics in dogs with thought to be the cause. acute diarrhea; both found that probiotics decreased the duration of diarrhea in dogs with acute idiopathic ANTIDIARRHEAL THERAPY diarrhea.20-23 Most cases of uncomplicated acute gastroenteritis When selecting a , it is important to that present with either small or large bowel diarrhea choose a product that has been subjected to adequate resolve without therapeutic intervention. Cases that quality control during the manufacturing process, present with diarrhea should have a fecal examination such as the ones listed in Table 4. and consider empirical deworming with a broad spectrum anthelminthic. However, there are a few Antimicrobial Therapy options for symptomatic treatment of diarrhea. Antimicrobial therapy with or tylosin is sometimes used empirically in dogs and cats with idiopathic acute gastroenteritis that present with Loperamide, an antimotility drug, has been either small or large bowel diarrhea. Both antibiotics used off-label in dogs with diarrhea. It decreases are used to potentially treat specific that intestinal motility and reduces mucosal secretions. may cause acute gastroenteritis (eg, Clostridium Doses used to treat diarrhea can cause neurologic perfringens). toxicity in dogs with the ABCB1 (formerly MDR1) However, a study evaluating the efficacy of mutation; therefore, avoid this drug in all dogs amoxicillin/ in dogs with acute carrying this allele and at-risk dog breeds (ie, Australian shepherd, Shetland sheepdog, long-haired hemorrhagic diarrhea syndrome (formerly called whippet, collie, English shepherd, German shepherd) hemorrhagic gastroenteritis) demonstrated no benefit 24 that have an unknown status. We do not recommend in treated dogs versus control dogs. Therefore, use of this drug for treating dogs or cats with acute routine therapy (including the use of gastroenteritis due to this potential toxicity and metronidazole) is not recommended in dogs or cats because the diarrhea associated with gastroenteritis is with acute gastroenteritis. usually self-limiting. Antibiotic therapy may have a role in dogs and cats suspected to have bacterial translocation through a Probiotics damaged gastrointestinal mucosal barrier, and this Probiotics are live that confer a is potentially more likely in cases of gastrointestinal health benefit on the host.16 These health effects bleeding. However, we reserve antimicrobial therapy are exerted by direct inhibition of colonization for patients with: by pathogenic microorganisms, or by immune- • More definitive evidence of translocation, such as enhancing effects on gut-associated lymphoid , elevated immature white blood cell tissue.17-19 count, and pyrexia Probiotics (Table 4) are sometimes used to treat • Leukopenia or those that are immunosuppressed dogs and cats with acute diarrhea. Each probiotic has • A specific bacterial enteropathogen (eg, a different formulation of bacteria, and it is unknown ) which, if any, are most useful for treatment of acute • Chronic diarrhea (as a therapeutic trial to rule out gastroenteritis with resultant diarrhea. Therefore, dysbiosis).

50 Today’s Veterinary Practice | November/December 2015 | tvpjournal.com SyMPTOMATIC MANAGEMENT OF PRIMARy ACUTE GASTROENTERITIS Peer Reviewed

NUTRITIONAL MANAGEMENT added dietary fi ber experienced signifi cant clinical improvement compared with dogs fed diets without The concept of complete fasting has been questioned added fi ber.25 in recent years for dogs with acute gastroenteritis. Complete restriction of food may be reasonable for a FLUID THERAPY short period, but an early return to appropriate oral Acute gastroenteritis can lead to fl uid losses and intake is advised unless contraindicated, such as in electrolyte imbalances that necessitate fl uid therapy. cases suspected to have foreign bodies. Subcutaneous Therapy Diet Considerations SC fl uid therapy may be appropriate for mild A wide variety of commercially available diets is dehydration or when outpatient therapy is marketed for dogs and cats with gastroenteritis. Each elected due to fi nancial concerns; however, it is formulated with slightly different protein and would be considered inappropriate for signifi cant carbohydrate sources and fat content; some contain dehydration or hypovolemia. SC fl uids should not other potentially benefi cial constituents, such as be supplemented with dextrose because bacterial fructooligosaccharides or omega-3 fatty acids. contamination and cellulitis can develop. Where Cats should receive enteral nutrition as soon as supplementation with dextrose is needed IV possible to avoid protein calorie , which administration is preferable. can lead to feline hepatic lipidosis. A commercially available, highly digestible diet is recommended. The Oral Therapy goal of feeding a highly digestible diet is to reduce Oral electrolyte solutions can be used in cases of the risk for . mild dehydration. In a recent study, this route of administration was safe and effective in dogs with Dietary Fiber hemorrhagic diarrhea.26 For patients with large bowel diarrhea, dietary fi ber is an important component of dietary management. While the optimal amount and type of dietary fi ber for treatment of dogs and cats with acute Goal-directed, targeted IV fl uid therapy to correct gastroenteritis are not known, there is general an estimated percent dehydration over a specifi c time agreement that, in dogs and cats: frame and to achieve normovolemia is recommended • Dietary fermentable fiber enhances normal colonic for moderate to severe dehydration or hypovolemia. function by providing a fuel source for colonocytes Balanced replacement crystalloid solutions, such as • Dietary nonfermentable fiber increases fecal bulk, lactated Ringer’s solution, are an appropriate choice which promotes normalized colonic motor in most patients. Ongoing monitoring of serum function and defecation. electrolyte concentrations is recommended because Potential sources include canned pumpkin, brown supplementation is sometimes required. rice, peas, and carrots. There are no established guidelines for fi ber supplementation in cases of small H2 = histamine-2; NK-1 = neurokinin-1; NSAID = bowel diarrhea. nonsteroidal anti-infl ammatory drug; PPI = proton In one study, dogs with that received pump inhibitor

YURI LAWRENCE JONATHAN LIDBURY Yuri Lawrence, DVM, MA, MS, Diplomate Jonathan Lidbury, BVMS, MRCVS, ACVIM (Small Animal Internal Medicine), Diplomate ACVIM (Small Animal Inter- is enrolled in the Texas A&M University nal Medicine) & ECVIM (Companion Gastrointestinal PhD program and also serves Animal), is an assistant professor of vet- as a senior clinician at the institution’s small erinary small animal internal medicine animal hospital. Dr. Lawrence received his at Texas A&M University. Dr. Lidbury DVM from Tufts University; then completed received his BVMS from University of an MA in anatomy and neurobiology at Glasgow in Scotland and completed Boston University, internship in small animal his small animal internal medicine res- medicine and at North Carolina State idency at Texas A&M University. His University, and residency in small animal clinical and research interests include internal medicine and MS in veterinary small animal and gastro- science at Oregon State University. enterology.

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References 1. Boscan P, Monnet E, Mama K, et al. Effect of maropitant, a neurokinin 1 receptor antagonist, on anesthetic requirements during noxious visceral stimulation of the ovary in dogs. Am J Vet Res 2011; 72(12):1576-1579. 2. de la Puente-Redondo VA, Tilt N, Rowan TG, Clemence RG. Efficacy of maropitant for treatment and prevention of emesis caused by intravenous infusion of cisplatin in dogs. Am J Vet Res 2007; 68(1):48-56. 3. Rau SE, Barber LG, Burgess KE. Efficacy of maropitant in the prevention of delayed vomiting associated with administration of doxorubicin to dogs. J Vet Intern Med 2010; 24(6):1452-1457. 4. Lorenzutti AM, Martin-Flores M, Litterio NJ, et al. Evaluation of the antiemetic efficacy of maropitant in dogs medicated with morphine and acepromazine. Vet Anaesth Analg June 2015 [epub ahead of print]. 5. Mason SL, Grant IA, Elliott J, et al. Gastrointestinal toxicity after vincristine or cyclophosphamide administered with or without maropitant in dogs: A prospective randomised controlled study. J Small Anim Pract 2014; 55(8):391- 398. 6. Hay Kraus BL. Efficacy of maropitant in preventing vomiting in dogs premedicated with hydromorphone. Vet Anaesth Analg 2013; 40(1):28-34. 7. Trepanier L. Acute vomiting in cats: Rational treatment selection. J Feline Med Surg 2010; 12(3):225-230. 8. Peroutka SJ, Synder SH. Relationship of neuroleptic drug effects at brain dopamine, serotonin, alpha-adrenergic, and histamine receptors to clinical potency. Am J Psychiatry 1980; 137(12):1518-1522. 9. Bersenas AM, Mathews KA, Allen DG, Conlon PD. Effects of ranitidine, famotidine, pantoprazole, and omeprazole on intragastric pH in dogs. Am J Vet Res 2005; 66(3):425-431. 10. Sutalo S, Ruetten M, Hartnack S, et al. The effect of orally administered ranitidine and once-daily or twice-daily orally administered omeprazole on intragastric pH in cats. J Vet Intern Med 2015; 29(3):840-846. 11. Tolbert K, Bissett S, King A, et al. Efficacy of oral famotidine and 2 omeprazole formulations for the control of intragastric pH in dogs. J Vet Intern Med 2011; 25(1):47-54. 12. Williamson KK, Willard MD, Payton ME, Davis MS. Efficacy of omeprazole versus high-dose famotidine for prevention of exercise-induced in racing Alaskan sled dogs. J Vet Intern Med 2010; 24(2):285-288. 13. Chandranath SI, Bastaki SM, Singh J. A comparative study on the activity of lansoprazole, omeprazole and PD-136450 on acidified ethanol- and indomethacin-induced gastric lesions in the rat. Clin Exp Pharmacol Physiol 2002; 29(3):173-180. 14. Tolbert MK, Odunayo A, Howell RS, et al. Efficacy of intravenous administration of combined acid suppressants in healthy dogs. J Vet Intern Med 2015; 29(2):556-560. 15. Sheen E, Triadafilopoulos G. Adverse effects of long-term proton pump inhibitor therapy. Dig Dis Sci 2011; 56(4):931-950. 16. Schrezenmeir J, de Vrese M. Probiotics, prebiotics, and synbiotics--approaching a definition. Am J Clin Nutr 2001; 73:361S-364S. 17. Sanders ME. Probiotics: Considerations for human health. Nutr Rev 2003; 61(3):91-99. 18. Macpherson AJ, Uhr T. Induction of protective IgA by intestinal dendritic cells carrying commensal bacteria. Science 2004; 303:1662-1665. 19. Isolauri E, Sütas Y, Kankaanpää P, et al. Probiotics: Effects on . Am J Clin Nutr 2001; 73(2):444S-450S. 20. Kelley RL, Minikhiem D, Kiely B, et al. Clinical benefits of probiotic canine- derived Bifidobacterium animalis strain AHC7 in dogs with acute idiopathic diarrhea. Vet Therap 2009; 10(3)121-130. 21. Bybee SN, Scorza AV, Lappin MR. Effect of the probiotic Enterococcus faecium SF68 on presence of diarrhea in cats and dogs housed in an animal shelter. J Vet Intern Med 2011; 25(4):856-860. 22. Herstad HK, Nesheim BB, L’Abée-Lund T, et al. Effects of a probiotic intervention in acute canine gastroenteritis—a controlled clinical trial. J Small Anim Pract 2010; 51:34-38. 23. Hart ML, Suchodolski JS, Steiner JM, et al. Open-label trial of a multi-strain synbiotic in cats with chronic diarrhea. J Feline Med Surg 2012; 14:240-245. 24. Unterer S, Strohmeyer K, Kruse BD, et al. Treatment of aseptic dogs with hemorrhagic gastroenteritis with amoxicillin/clavulanic acid: A prospective blinded study. J Vet Intern Med 2011; 25(5):973-979. 25. Leib MS. Treatment of chronic idiopathic large-bowel diarrhea in dogs with a highly digestible diet and soluble fiber: A retrospective review of 37 cases. J Vet Intern Med 2000; 14(1):27-32. 26. Reineke EL, Walton K, Otto CM. Evaluation of an oral electrolyte solution for treatment of mild to moderate dehydration in dogs with hemorrhagic diarrhea. JAVMA 2013; 243(6):851-857.

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