Diagnosis and Dietary Management of Gastrointestinal Disease

Quick Resource Guide Diagnosis and Dietary Management of Gastrointestinal Disease

For information about Purina Veterinary Diets,® call the Veterinary Resource Center Deborah S. Greco at 1-800-222-VETS (8387) weekdays, 8:00 am to 4:30 pm CT, DVM, PhD, DACVIM or visit our website at PurinaVeterinaryDiets.com.

VET 2229B-0711 Trademarks owned by Société des Produits Nestlé S.A., Vevey Switzerland Printed in the U.S.A. Quick Resource Guide Diagnosis and Dietary Management of Gastrointestinal Disease

HISTORY-TAKING TIPS DIAGNOSTIC TEST TIPS

■ Diagnosing GI disease...... 4 ■ Urinalysis...... 12

■ Basic considerations...... 4 ■ Basic fecal exam & other fecal tests...... 12

■ Obtaining a dietary history...... 5 ■ Fecal scoring...... 13

■ CHECKLIST – History...... 5 ■ Serologic tests...... 14 CBC...... 14 ■ Patient history worksheet...... 6 Serum chemistry...... 15 PHYSICAL EXAMINATION TIPS ■ Intestinal function tests...... 14 ■ First things first...... 7 ■ Radiography versus ultrasound...... 14 ■ Posture, behavior & attitude...... 7 ■ Endoscopy versus laparotomy...... 14 ■ Vital signs & physical condition...... 7 GI ALGORITHMS ■ Localizing GI disease...... 7 ■ Combined canine & feline...... 16–27 ■ Distinguishing vomiting from regurgitation...... 7 PURINA VETERINARY DIETS® FOR GI SUPPORT ■ Distinguishing small from large bowel diarrhea...... 7 ■ Combined canine & feline...... 28–34 ■ CHECKLIST – GI disease...... 8

■ Head & mouth...... 8

■ Auscultation of the chest...... 8

■ Abdominal palpation & fecal exam...... 8

■ Diagnostic tests...... 9

■ Algorithms for decision making...... 9

■ Canine body condition system...... 10 Deborah S. Greco, DVM, PhD, DACVIM

■ Feline body condition system...... 11

DIAGNOSis at your fingerTIPS

Download our free iPhone GI Diagnostic app for easy access to the diagnostic algorithms. Make diagnosis of your patients’ condition easier than ever — wherever you are.

History-Taking Tips

gastrointestinal (gi) problems are a common complaint at veterinary hospitals. localizing the problem is the first step in making a correct diagnosis. in addition to taking a history, performing the physical exam and obtaining a minimum database, the use of timesaving gi algorithms can help trace normal and abnormal signs, test results, rule-outs, and next steps toward resolving the problem.

Diagnosing GI disease Although one may be tempted to take a cursory history for a seemingly simple complaint, a thorough evaluation of all body systems may be necessary to determine the cause of GI signs. Often the more nebulous the problem, the more important the history. Not only is the GI tract the way food — and sometimes a foreign object — enters the body, the GI tract is of paramount importance in maintaining the overall health of the pet. It is the means for nourishment and elimination of waste and an important route for drug delivery. In addition

to what goes into and is assimilated (or not) by the GI tract, • Localize the cause and determine if the condition is primary underlying disease can have an effect on GI function. Secondary or secondary GI disease. Identifying the location of the GI disease is caused by an underlying disorder (or disorders that problem will assist in choosing a plan of action — may lie outside of the intestinal tract), but primary GI disease e.g., laparotomy for investigating generalized bowel disease is concerned only with the GI tract and its functionality. versus colonoscopy for primary large bowel disease.

Listening to the pet owner while getting a history is as important • Signalment may be very important. In an unvaccinated as the physical exam and appropriate testing. Information young puppy with fever, anorexia, vomiting and profuse bloody on day-to-day eating and elimination habits, food types, and diarrhea, infectious causes such as parvo or distemper virus observed behavior helps in selecting the appropriate diagnostic would be at the top of the list of suspects. In a kitten from a cattery, Tritrichomonas may be one of the first pathogens to tests and making beneficial therapeutic recommendations. look for if large bowel diarrhea is the complaint. Weight loss The owner can assist in this by filling out a written history before with an increased appetite has fewer differentials (eg, diabetes the pet’s visit, or at least prior to the examination. mellitus in the dog, hyperthyroidism in the cat) than does weight loss with anorexia. Questions about the general health Basic considerations of the pet, such as the presence of polyuria/polydipsia, may • Recognize the difference between vomiting and help narrow the differential list. regurgitation as well as the difference between small and large bowel disease — key to correctly diagnosing • Take the time to ask open-ended questions of the pet and treating GI disease. owner — it will pay off in the long run with valuable clues for the selection of diagnostics. For example, if you ask the • Ask questions directed at the presenting complaint. owner: “Does your dog have diarrhea?” The answer may be For example, for a complaint of constipation and dehydration: “no,” as the owner has not observed the dog’s stools because “Does your dog/cat drink or urinate excessively?” it defecates outside the house. If the question is asked in an This type of question may help differentiate secondary open-ended manner, such as: “Describe your dog’s stools,” constipation caused by renal disease from primary then the client is free to elaborate on the type of abnormalities gastrointestinal disease. that may have been observed.

CHECKLIST — History obtaining a dietary history The dietary history is another key component for diagnosing • Localize the problem. GI disease. It can assist in identifying dietary indiscretions • Note the pet’s physical condition and BCS. up front as well as help pinpoint the need for a change in food or • Recognize the difference between vomiting and regurgitation. for dietary support for an underlying condition. • Recognize the difference between small and large An additional concern is that clients are often misinformed bowel diarrhea. about dietary concerns in GI disease and may give confusing or • Be precise in determining the primary complaint. incorrect information about a pet’s eating habits. The history • Ask owners open-ended questions, not leading questions. questionnaire on page 6 includes dietary information and is often the best and most expedient way of dealing with the more • Listen to the owner — only he or she knows this pet’s common areas of misunderstanding, such as: particular habits.

• Treats and other dietary items (table food, vitamins, etc.) • Ask owners to describe the stool or vomitus in their are often not perceived as part of a pet’s diet. own words.

• More than one family member feeding food or treats • Don’t rush the owner. without mentioning it to the primary caregiver, or the • Don’t ignore, but don’t give too much weight to, previous consumption of food intended for other household pets. medical complaints or diagnoses.

• Withholding certain foods, food flavors, or foods with • Don’t try to lump all complaints into one diagnosis, which certain ingredients such as corn or wheat because of worries can result in early exclusion of the correct diagnosis. about “allergies” or other misinformation. • Don’t assume that “common diseases occur commonly.” • Some clients may be embarrassed or unwilling to divulge • Pay attention to dietary history and signalment. exactly what and how much is being fed to their pet for fear of • Use history forms that owners can fill out before the visit being judged negatively. or in the waiting room.

a concern is that clients are often misinformed about dietary concerns in gi disease and may give confusing or incorrect information about a pet’s eating habits.

Patient History Worksheet Please fill out before hospital visit or in the waiting room

Pet’s Name ______A g e _____ B r e e d ______Cat Dog Male Female Neutered Spayed signs — vomiting or regurgitation • Any toys/nonfood items/small household objects missing? ______•_Is there abdominal effort or is it more of a passive act?______•_Any change in exercise habits?______•_How many times a day?______•_Any change in behavior, eyesight, body posture?______•_What is the character of the vomitus?______•_Is food digested?______Or undigested?______•_Any change in your household environment (eg, remodeling, •_Are there any nonfood items? ______relocation, new members, absent members, new pets)?____ •_Is there any fresh blood?______•_Is there a “coffee grounds” appearance?______•_What is the shape of the vomitus?______dietary history •_Does your pet have bad breath?______•_Is the pet food homemade, raw, commercial?______•_Is it primarily dry food, canned food, or a mixture of dry and signs — diarrhea canned foods?______•_How many stools a day?______•_ If it’s a commercial food, what brand, formula and flavor is it? •_What is the character of the stools?______•_Is there any fresh blood?______•_If the food is homemade, what are the ingredients and •_Is there any mucus?______amounts of each ingredient?______•_Are the stools bulky?______Or thin?______•_What is the shape of the stools?______•_Is the stool color normal for your pet?______•_How long has the food been fed?______•_What color is the stool?______•_How frequently is the type of food changed?______•_When was the type of food last changed?______history •_How much food is actually eaten per day?______•_How long has your pet been ill?______•_How is food measured (weight vs volume)?______•_Has your pet lost weight?___ How much?______•_Is your pet exclusively indoors?______Outdoors?______•_Is the pet fed ad libitum or with measured portions?______Or both?______•_How many dogs are in your household?______•_How many times per day is the pet fed?______•_How many cats are in your household?______•_Who feeds the pet (ages of children, grandparents, etc)?___ •_Any other pets?______•_If there are other pets in the household, what are they being •_What is your pet’s vaccination history?______fed?______•_Does the pet have access to the outdoors?______•_Does your pet have a chronic condition (arthritis, diabetes, •_Does the pet receive additional items (treats, vitamins, etc)? etc)?______•_Is your pet taking any drugs (heartworm preventative, dewormer, digoxin, NSAID, etc)?______•_Does the pet receive “people food”?______•_Does your pet have access to garbage or “people food”? •_Are medications administered by mouth or in food (amount ______and type)?______•_Any change in water consumption?______•_Does the pet eat nonfood items (tissues, clothing, diapers, etc)? •_Any change in urination habits?______•_Difficulty defecating?______•_Is milk given?______•_Any access to household or garden chemicals?______•_Is fresh water provided daily?______

Physical Examination Tips

Localizing GI disease first things first Once a history and dietary information have been taken, Upper GI the next step is to assess the presenting GI problem. • Regurgitation – Esophageal disease; gastric motility Tips for Localizing GI disease as well as Distinguishing disorder vomiting from regurgitation and Distinguishing small • Excessive salivation – Hepatic encephalopathy in cats, foreign body in dogs from large bowel diarrhea are located on this page. They will • Oral ulceration – Chronic kidney disease, aid in the physical exam, selecting diagnostic tests and using the immunocompromise (FIV, FeLV in cats) diagnostic GI Algorithms on pages 16 through 27. • Halitosis – Foreign body, chronic small bowel problem, periodontitis posture, behavior & attitude Lower GI • Lack of alertness may indicate metabolic problems such as • Borborygmus – Noises from abnormal carbohydrate hepatic encephalopathy. and protein fermentation are indicative of colitis, • Abnormal posture eg, animals with severe pancreatitis may inflammatory bowel disease or antibiotic-responsive assume the “praying” position in an effort to alleviate cranial diarrhea. abdominal pain. • Guarded abdomen – Pain because of an obstruction • Generalized muscle weakness along with GI signs is — Left cranial abdomen for hepatic pain — Dorsal for cecum characteristic of hypoadrenocorticism. — Dorsocranial for intussusception • Salivation and “lip smacking” indicate nausea, gastric or — Right cranial for pancreatitis esophageal foreign bodies, or hepatic encephalopathy in cats.

• Aversion to food can be a sign of nausea. DistinguisHing vomiting from regurgitation • Distended abdomen may indicate ascites, a large vomiting regurgitation abdominal tumor, or gas accumulation due to gastric Active (abdominal Passive (no abdominal dilatation/volvulus (GDV). contractions) contractions) Unrelated to food intake Shortly after eating Vital signs & physical condition • Systemic signs, such as fever, tachycardia or poor physical Digested food Undigested food condition, may indicate whether a GI problem is primary Bile/blood No bile/blood or secondary. Low pH Neutral pH • Body condition score (BCS charts on pages 10 and 11) helps to assess general wellness and physical condition and DistinguisHing small from large allows for comparison each time the pet is seen. The impact bowel diarrhea of chronic disease on weight gain or weight loss (and SIGN small bowel large bowel vice versa) can assist in making a correct diagnosis and recommending dietary support. Constipation/ Rare Common tenesmus • Hydration abnormalities, such as increased capillary refill Frequency Normal to 2 to 3x > 3x normal time, tacky membranes and skin turgor, may indicate normal dehydration severity. Urgency Uncommon Common

• Eye and skin signs, such as pallid sclera and membranes, Volume Increased Decreased numerous small points of hemorrhage (petechiation), and Mucus Rare Common yellowing of skin and whites of the eyes (icterus), may indicate systemic disease. Fresh blood Uncommon Common Weight loss Common Uncommon

CHECKLIST — GI Disease Auscultation of the chest A complete picture of the patient • Air, fluid, abnormal heart rhythms, etc. For example, is needed to differentiate primary bradycardia is characteristic of hypoadrenocorticism from secondary GI disease. or can indicate increased vagal tone. Heart murmurs may • History indicate anemia. • Dietary history • Fluid in the chest and abdomen can be caused by heart • BCS failure, liver disease resulting in hypoalbuminemia, or protein- • Localization losing enteropathies (PLE).

• Vomiting vs regurgitation • Arrhythmias or cardiac murmurs would indicate that heart • Small vs large bowel diarrhea failure is a possibility and that GI signs may be secondary to venous congestion in the intestines. • Acute (presence of mucus or blood) • Chronic • Abnormal lung sounds may indicate aspiration pneumonia secondary to megaesophagus. • Physical examination • Increased respiratory rate or dyspnea may indicate • Diagnostic tests esophageal problems, such as foreign bodies that can • Algorithms for decision making cause pain.

Abdominal palpation & fecal exam • Identify each organ in the abdominal cavity starting with Head & mouth the liver, followed by the kidneys (easier to palpate in the cat), • Tongue should be examined at the root in order to rule out bladder, spleen and intestines. string or foreign bodies. • Assess each organ for size (is the liver protruding past the • Loss of senses (sight or smell), presence of dental disease ribs?), symmetry and texture. or temporal muscle atrophy (myositis) may indicate a secondary cause for anorexia (pseudoanorexia). • Intestinal lymph nodes may be palpable, in the mesentery if enlarged. • Neck and throat palpation may reveal foreign bodies or pain indicative of underlying disease, as in dysphagia (difficulty • Intussusception of the intestine will be identified by the swallowing) or regurgitation. presence of a large, firm tubular section of bowel. • Foreign bodies such as bones, peach pits, corncobs and plastic toys may be readily palpable, depending on their location within the intestine.

• Palpate cranial abdomen (lift the forelegs) for additional assessment of the internal organs.

• Rectal/fecal examination – Rectum and anus should be palpated 360° for the presence of tumors, thickening or foreign material. Pay particular attention to the anal sacs to rule out impaction or tumors; expression of the anal sacs establishing a systematic will help to determine the location of a mass if detected. gi exam routine will aid in This is an excellent opportunity to obtain a stool sample for identifying abnormalities. fecal examination.

Diagnostic tests for GI disease Diagnostic tests Test results help differentiate primary from secondary Tests for MDB disease and can help pinpoint treatment and dietary support • Urinalysis (including urine specific gravity) protocols. Start with the minimum database (MDB) and • Fecal direct examination/scoring add appropriate tests as needed for species, breed, age and • Fecal parasite examination circumstances. See DIAGNOSTIC TEST TIPS section on • Fecal cytology pages 12 through 15 for common differentials. • Complete blood count (CBC) • Serum chemistry profile

Algorithms for decision making • TT 4 (total thyroxine) Along with the history, physical examination and diagnostic tests, the GI Algorithms provided on pages 16 through 27 Additional tests as needed • Canine virology (parvovirus) are designed to assist the practitioner in differentiating • Feline virology (FeLV, FIV) disease as well as making decisions for treatment and • Pancreatic lipase immunoreactivity (dog = cPLI, cat = fPLI) dietary support protocols. It is important to keep in mind • Malabsorption profile (trypsin-like immunoreactivity, what judgements have already been made during history vitamin B and folate) taking, the physical exam and minimum database collection 12 • Fecal alpha-1 protease when using the algorithms. The animal’s condition and • Thoracic and abdominal radiography, ultrasonography, circumstances also are important because GI disease can laparotomy be complicated.

every pet visit should include a body condition assessment that is recorded in the patient file for comparison from visit to visit (see next page for purina body condition system™ guidelines).

Canine BCS

Ribs, lumbar vertebrae, pelvic bones and all bony prominences evident from a distance. No discernible body fat. Obvious loss ] of muscle mass.

Ribs, lumbar vertebrae and pelvic bones easily visible. 1 No palpable fat. Some evidence of other bony prominence. Minimal loss of muscle mass. TOO THIN Ribs easily palpated and may be visible with no palpable fat. Tops of lumbar vertebrae visible. Pelvic bones becoming ] prominent. Obvious waist and abdominal tuck. 3 Ribs easily palpable, with minimal fat covering. Waist easily noted, viewed from above. Abdominal tuck evident.

Ribs palpable without excess fat covering. Waist observed

IDEA L behind ribs when viewed from above. Abdomen tucked up when viewed from side. ]

Ribs palpable with slight excess fat covering. Waist is 5 discernible viewed from above but is not prominent. Abdominal tuck apparent.

Ribs palpable with difficulty; heavy fat cover. Noticeable fat deposits over lumbar area and base of tail. Waist absent or ] barely visible. Abdominal tuck may be present.

Ribs not palpable under very heavy fat cover, or palpable 7 only with significant pressure. Heavy fat deposits over lumbar area and base of tail. Waist absent. No abdominal tuck. TOO HEAVY Obvious abdominal distention may be present.

Massive fat deposits over thorax, spine and base of tail. Waist and abdominal tuck absent. Fat deposits on neck ] and limbs. Obvious abdominal distention.

The BODY CONDITION SYSTEM was developed at the Nestlé Purina Pet Care Center and has been 9 validated as documented in the following publications: Mawby D, Bartges JW, Moyers T, et. al. Comparison of body fat estimates by dual-energy x-ray absorptiometry and deuterium oxide dilution in client owned dogs. Compendium 2001; 23 (9A): 70 Laflamme DP. Development and Validation of a Body Condition Score System for Dogs. Canine Practice July/August 1997; 22:10-15 Kealy, et. al. Effects of Diet Restriction on Life Span and Age-Related Changes in Dogs. JAVMA 2002; 220:1315-1320 Call 1-800-222-VETS (8387), weekdays, 8:00 a.m. to 4:30 p.m. CT

Feline BCS

Ribs visible on shorthaired cats; no palpable fat; 1 severe abdominal tuck; lumbar vertebrae and wings ] of ilia easily palpated. 1

Ribs easily visible on shorthaired cats; lumbar vertebrae 2 obvious with minimal muscle mass; pronounced abdominal tuck; no palpable fat.

Ribs easily palpable with minimal fat covering; lumbar vertebrae obvious; obvious waist behind ribs; minimal

TOO THIN 3 abdominal fat. ] 3

Ribs palpable with minimal fat covering; noticeable 4 waist behind ribs; slight abdominal tuck; abdominal fat pad absent.

Well-proportioned; observe waist behind ribs; ribs palpable 5 with slight fat covering; abdominal fat pad minimal. ] 5 IDEAL

Ribs palpable with slight excess fat covering; waist and 6 abdominal fat pad distinguishable but not obvious; abdominal tuck absent.

Ribs not easily palpated with moderate fat covering; waist poorly discernible; obvious rounding of abdomen; 7 7 moderate abdominal fat pad. ]

Ribs not palpable with excess fat covering; waist absent; 8 obvious rounding of abdomen with prominent abdominal

TOO HEAVY fat pad; fat deposits present over lumbar area.

Ribs not palpable under heavy fat cover; heavy fat 9 deposits over lumbar area, face and limbs; distention of 9 abdomen with no waist; extensive abdominal fat deposits. ]

Call 1-800-222-VETS (8387), weekdays, 8:00 a.m. to 4:30 p.m. CT

Diagnostic Test Tips

Urinalysis PART 2 – Fecal parasite examination. Flotation may Urine evaluation can give an overall indication of health identify nematode worm eggs such as Toxocara and and can also be used to rule diseases in or out. A lot has been Ancylostoma. It may be helpful to use zinc sulfate centrifugation written about urinalysis, but here are a few key issues for whipworm eggs (Trichuris) and Giardia cysts. As primary for GI disease. parasites, ascarids (Toxocara and Toxascaris) are rarely a cause of diarrhea, but a large infestation can obstruct a small puppy or • Hydration status • Urinary tract infection kitten’s GI tract, resulting in vomiting.

• Kidney function • Endocrine disease (diabetes) PART 3 – Fecal cytology. A simple smear of feces or rectal scraping can be stained with Diff-Quik (Romanowski • Protein-losing nephropathy stain) to identify cells such as neutrophils and eosinophils. Basic fecal examination Characteristically shaped “safety pin” spores of Clostridium The basic fecal examination is one of the most important or spirochetes such as Campylobacter may be identified aspects of the minimum database for GI disease. The basic fecal under the microscope at high power. Acid-fast stains may exam consists of three parts. identify Cryptosporidium and mycobacteria. In endemic areas, intracellular fungal infections, such as with Histoplasma, may be PART 1 – Direct examination. Look for abnormal color found. or consistency, and observe and record shape if possible (see Fecal scoring on opposite page). Acholic (colorless or Other fecal tests pale) stools may indicate exocrine pancreatic insufficiency (EPI) Fecal antigen tests – If a thorough fecal exam, including or bile duct obstruction. The stool should be examined for the direct smear (feces mixed with saline), flotation and zinc sulfate presence of melena, fresh blood, mucus or nonfood material centrifugation is negative for Giardia, a fecal Giardia antigen test may (string, carpet, plastic, rock). Greasy stools are indicative be indicated. Approximately 25% of Giardia patients can be negative of EPI or malabsorptive conditions, such as protein-losing on fecal exam, but positive for Giardia antigen. A young puppy enteropathies (PLE). Put a small amount of stool on a glass with a history of vomiting and diarrhea should have a parvovirus slide with a coverslip. In cats, look for Tritrichomonas foetus, antigen test to rule out this potentially fatal disease. particularly in kittens from catteries. Giardia trophozoites may Fecal culture – If the dietary history indicates that a raw food also be detected by direct smear (feces mixed with saline). diet is being fed, a Salmonella culture may be indicated. In some Coccidian oocysts (protozoa) may be observed. cases, overgrowth of pathogens such as drug-resistant E coli and Campylobacter may induce chronic relapsing diarrhea. In such cases, fecal culture may be helpful. G. Taton-Allen G. Taton-Allen J. Michael Harter, DVM

Campylobacter organisms in fecal smear. Notice the small size compared to normal Toxascaris and Toxocara eggs bacteria in the sample. Giardia trophozoites

Fecal scoring

Score 1 Score 5 Very hard and dry; often Very moist, but has a expelled as individual distinct shape; piles pellets; requires much rather than distinct logs; effort to expel from leaves residue and loses body; no residue left on form when picked up. ground when picked up.

Score 2 Score 6 Firm, but not hard; Has texture, but no pliable; segmented in defined shape; present appearance; little or no as piles or spots; leaves residue on ground when residue when picked up. picked up.

Score 3 Score 7 Log-shaped; little or no Watery; no texture; visible segmentation; flat puddles. moist surface; leaves residue on ground, but holds form when picked up.

Score 4 Fecal consistency is primarily a function of the amount of Very moist, soggy; log- moisture in the stool and can be used to identify changes in shaped; leaves residue colonic health and other problems. Ideally, in a healthy animal, and loses form when stools should be firm but not hard, pliable and segmented, and picked up. easy to pick up (Score 2).

examination of an entire stool along with fecal scoring provides insight into the function of the intestinal tract and a baseline for assessing improvement.

CBC results — Some possible differentials Serologic tests Finding Indication(s) • Complete blood count (see CBC results chart) Macrocytosis without Hyperthyroidism • Serum chemistry profile (see Serum chemistry profile anemia results chart) High PCV Severe dehydration

• TT4 – Thyroid status may help explain some GI signs. Low PCV Vitamin B12 deficiency, bleeding tumor, ulcers, exocrine • Virology – Tests for FeLV and FIV (feline) and parvovirus pancreatic insufficiency (EPI), (canine) can explain possible primary GI disease signs. liver disease Hypochromic microcytic Chronic blood loss such as from Intestinal function tests anemia GI bleeding Most intestinal function tests are not practical in clinical Leukopenia Parvovirus, panleukopenia settings, but can be helpful in assessing the following: Lymphopenia Lymphangiectasia • Serum trypsin-like immunoreactivity (TLI) may be helpful Inflammatory leukogram Infectious diarrhea in assessing pancreatic insufficiency.

B12 deficiency Macrocytic anemia • Serum pancreatic lipase immunoreactivity (PLI) (pancreatic disease or ileal may be helpful in assessing pancreatitis. Specific feline and inflammation in cats) canine tests are available. Negative stress leukogram Hypoadrenocorticism (dogs) Eosinophilia Parasitism, neoplasia • Serum vitamin B12 (cobalamin) may be used to assess deficiency resulting from ileal disease or pancreatic insufficiency. PCV = packed cell volume • Serum folate levels increase with bacterial overgrowth and in antibiotic responsive diarrhea.

• Fecal alpha-1 protease may be an indicator of early PLE.

Radiography versus ultrasound • Abdominal ultrasonography may be very helpful to assess • Abdominal radiography is of limited value in most chronic the location of disease within the GI tract. Specifically, disorders. In acute vomiting cases, however, radiographs are ultrasound may be helpful in detecting gastric ulceration, indicated to rule out foreign bodies, gastric dilatation/volvulus gastric masses and thickening of the stomach lining. The (GDV), intussusception and obvious tumors. intestines can be assessed for localized disease (eg, ileal • Thoracic radiography is helpful in assessing the esophagus tumor) and thickening and enlargement of mesenteric lymph in cases of retching or regurgitation. nodes, which may indicate neoplasia. The liver and pancreas also can be evaluated.

Endoscopy versus laparotomy • Endoscopy with guided biopsy can be a valuable tool if the history and physical exam, MDB, and ancillary tests indicate the location of the lesion within the GI tract or the clinician suspects generalized GI disease or disease localized to the stomach, duodenum or colon. The risk of dehiscence is low with endoscopic biopsies; therefore, this is the method of most intestinal function choice for dogs with fragile intestines and low protein due tests are not practical to PLE. Endoscopy can be performed multiple times. There in clinical settings, but are limitations, of course, including small biopsy size, forceps can be helpful in assessing artifacts on biopsies, inability to biopsy the jejunum and, most primary disease. important, the inability to obtain full-thickness samples.

Serum chemistry profile results — Some possible differentials

Finding Indication(s)

Decreased Na/K ratio Hypoadrenocorticism, whipworm infection, third David© Dr. Twedt space fluid accumulation Decreased Ca and Mg PLE

Increased P, BUN/CREA Renal disease

Increased BUN/CREA Hypoadrenocorticism, renal disease, whipworms

Increased liver enzymes Liver disease, hyperthyroidism, A barium-food mixture esophogram in a cat showing dilatation of the cervical pancreatitis, gallbladder disease esophagus with a luminal narrowing at the thoracic inlet (arrow). Decreased total protein PLE (TP) Decreased albumin PLE, PLN, liver disease

Decreased cholesterol PLE

Increased ALP Biliary disease

Increased ALT Hepatic necrosis, toxic

hepatopathy, compromised Baker, UC Davis© Tom GI function

ALP = alkaline phosphatase Mg = magnesium ALT = alanine aminotransferase Na = sodium BUN = blood urea nitrogen P = phosphorus Ca = calcium PLE = protein-losing enteropathy CREA = creatinine PLN = protein-losing nephropathy K = potassium Ultrasound of normal liver and stomach.

• Exploratory laparotomy with full-thickness biopsies might be indicated if the history and physical exam indicate that the gastrointestinal disease is localized — particularly if there is a suggestion of duodenal, jejunal or ileal involvement. The disadvantage of exploratory surgery is the length of anesthesia and the risk of dehiscence, particularly in patients with low serum protein. The advantage is that the biopsies are full thickness, multiple organs can be biopsied, and the biopsies can be taken from grossly affected tissues within the abdominal cavity.

imaging and biopsy are valuable tools for localizing and identifying primary or Endoscopic appearance of the proximal duodenum of a dog with inflammatory bowel disease showing marked granularity secondary disease. of the mucosa, consistent with diffuse inflammation.

GI Algorithms

DIAGNOSis at your fingerTIPS COMBINED CANINE & FELINE

Download our free iPhone GI Diagnostic app ■ Anorexia...... 18 for easy access to the following diagnostic algorithms. ■ Constipation/tenesmus...... 19

■ Diarrhea, acute...... 20

■ Diarrhea, chronic (small bowel)...... 21

■ Diarrhea, chronic (large bowel)...... 22

■ Flatulence/borborygmus, chronic...... 23

■ Regurgitation, dysphagia...... 24

■ Vomiting, acute...... 25

■ Vomiting, chronic...... 26

■ Weight loss...... 27

the gi algorithms on the following pages employ the abbreviations and conventions below and indicate which purina veterinary diets® formulas are appropriate in each situation.

Abbreviations Purina Veterinary Diets® & supplements for GI support* ACh Acetylcholine ACTH Adrenocorticotropic hormone DCO Dual Fiber Control® Canine Ag Antigen DM Dietetic Management® Feline BCS Body condition score ® BW Body weight DRM Dermatologic Management Canine BUN/CREA Blood urea nitrogen/creatinine EN Gastroenteric® Canine & Feline CKD Chronic kidney disease Hypoallergenic® Canine & Feline CSF Cerebrospinal fluid HA cPLI Canine pancreatic lipase NF Kidney Function® Canine & Feline immunoreactivity ® cTSH Canine thyroid stimulating hormone OM Overweight Management ELISA Enzyme-linked immunosorbent assay Canine & Feline EPI Exocrine pancreatic insufficiency FortiFlora® Nutritional Supplement fPLI Feline pancreatic lipase immunoreactivity GDV Gastric dilatation/volvulus Complete listing available at PurinaVeterinaryDiets.com. GSD German shepherd dog H Hour Legend IBD Irritable bowel disorder IgA Immunoglobulin A GI Algorithms apply to both dog and cat. When they K + Ionized potassium differ, the canine diet recommendation is in GREEN MCT Medium-chain triglycerides MDB Minimum database and the feline diet recommendation is in BLUE. Na Sodium ■ Canine ■ Feline NSAIDs Nonsteroidal anti-inflammatory drugs PE Physical exam ABNORMAL Pursue Diagnosis P Protein PLE Protein-losing enteropathy Normal Rule Out PLN Protein-losing nephropathy PEG Percutaneous endoscopic gastrostomy RAA Right aortic arch RER Resting energy requirement SIBO Small intestinal bacterial overgrowth SpGr Specific gravity TLI Trypsin-like immunoreactivity

TT4 Total thyroxine UA Urinalysis UPC Urine protein:creatinine ratio URI Upper respiratory infection *For information about Purina Veterinary Diets,® call the UR Urine Veterinary Resource Center at 1-800-222-VETS (8387) Vit Vitamin weekdays, 8:00 am to 4:30 pm CT, or visit our website at PurinaVeterinaryDiets.com.

DIAGNOSIS

NORMAL while pursuing diagnosis. Specific therapy or therapy Specific Provide appropriate nutritional support PURSUE * ABNORMAL GO TO PAGES 25, 26 TOGO PAGES GO TO PAGES 20, 21, 22 TOGO PAGES VOMITING ALGORITHMS VOMITING DIARRHEA ALGORITHMS NORMAL with signs GI Survey radiographs Survey * OUT

fPLI, ultrasound fPLI, RULE NORMAL - pancreatitis CAT oral exam, BCS,B MD Perform diet PE, history, endoscopy, biopsy endoscopy, Chest radiographs Chest Biopsy, radiographs, OUT retrobulbar or retrobulbar

removal of affected teeth affected of removal Respiratory disease Respiratory pharyngeal myositis Neurologic vestibular disease Pseudoanorexia, of loss disease, cerebral disease cerebral disease, RULE Dental disease/stomatitis, senses, blindness, anosmia blindness, senses, Treat otherTreat primary ABNORMAL ia x nore A

Anorexia

DIAGNOSIS

Canine & Feline ® Feline Neurologic deficit ® G PURSUE Canine ® I A Canine & Feline ® lgorithms IBD OUT OUT , EXAM

parasites OM OverweightOM Management DM DieteticDM Management DCO Dual Fiber Control NF KidneyNF Function RULE RULE PURINA VETERINARY DIETS NSAID FECAL ABNORMAL foreign body, neoplasia, Hematochezia Polyp Neoplasia old or new Foreign body Perineal hernia Pelvic fracture, Pelvic Anal sac disease Biopsy/removal/repair Mass or anatomic defect exam, diet history Perform rectal PE, 4 , + T DIAGNOSIS

Fluids, Hypothyroid to DCO, insulin Supplement K change diet to NF DOG – change diet PURSUE Hypokalemia CAT – changeCAT diet to DM, insulin or oral hypoglycemics High BUN/CREA, (diabetes mellitus) (diabetes low UR SpGr UR low (CKD) ABNORMAL High fructosamine, glucose Elevated cTSH, reducedElevated T cTSH, & cTSH 4 T NORMAL Perform MDB DOG – T CAT – neuro exam, CAT abdominal radiographs abdominal NORMAL Idiopathic modifiers, fluids Stool softeners, motility Constipation tenesmus CAT – changeCAT diet to OM DOG – change diet to DCO

Constipation tenesmus 19

FortiFlora, ABNORMAL change diet to Anthelmintics, CAT – EN or – EN OM CAT DOG – DCO or EN antibiotics indicated, if Yes RESPONSE

Large Bowel Large parasite exam Fecal cytology, NO ALGORITHMS GO TO PAGE 22 TOGO PAGE CHRONIC DIARRHEA lgorithms A I NORMAL Empirical FortiFlora, G anthelmintics, change diet to CAT – EN or – EN OM CAT DOG – DCO or EN RESPONSE Continue diet NORMAL BW? Urgency? BW? ALGORITHMS GO TO PAGE 21 TOGO PAGE 4 TO Increased frequency? T

Blood? Mucus? Normal CHRONIC DIARRHEA Perform diet PE, history SEVERE CAT – T CAT MODERATE DOG – Parvovirus test Perform fecal MDB, exam OUT

RULE ABNORMAL viral enteritis DOG – Addison’s, toxins, parasites; CAT – hyperthyroid CAT mass, intussusception mass, treat specific disease, No Dehydrated? Small Bowel Clinical signs?

® RESPONSE

NO ALGORITHMS GO TO PAGE 21 TOGO PAGE

Canine & Feline CHRONIC DIARRHEA ® mall From Large From mall Canine MILD ® ± FortiFlora then EN diet,then EN * Canine & Feline A Withold food H, 24 ® on page 7. ® RESPONSE RRHE Continue diet, EN FortiFlora needed if IA Bowel Diarrhea Bowel See also S Distinguishing OM OverweightOM Management DCO Dual Fiber Control FortiFlora EN GastroentericEN D acute PURINA VETERINARY DIETS *

* DIARRHEA acute 20

, G ONLY I

A intestines, ABNORMAL with biopsy DOG lymphadenopathy lgorithms DRM orDRM diet HA Endoscopy/laparotomy ONLY Serum IgA in GSD,

PLE change diet or to EN HA Lymphangiectasia therapy, Lymphangiectasia DOG specific therapy, FortiFlora Lymphangiectasia, breed-specific diseases breed-specific OUT

RULE ABNORMAL ABNORMAL hepatopathy ± low albumin± low liver ultrasoundliver portosystemic shunts, portosystemic infection, inflammatory ± elevated enzymes liver Lymphoma Eosinophilic Neutrophilic, inflammation lymphoplasmacytic RESPONSE

4 Specific therapy, Specific T change diet to EN NO change diet to anthelmintics, CAT – EN or – EN HA CAT Specific therapy, Specific change diet to EN change diet to HA DOG or HA DRM – EN, OUT

Specific therapy, FortiFlora, RULE Addison’s, Increased K Decreased Na Decreased ACTH stimulationACTH Abnormal electrolytes , supplement, 12 DIAGNOSIS

radiography or ultrasound, – T CAT FortiFlora FortiFlora, 12 Perform diet PE, history, abdominal MDB, change diet to EN change diet to EN change diet to EN PURSUE Antibiotics for SIBO, Pancreatic supplement,Pancreatic Low B Low TLI Parenteral B Increased folate ABNORMAL

® & folate & 12

Canine NORMAL

® TLI, B bowel

mall From Large From mall NORMAL ) * Canine & Feline ® Canine & Feline A ® change diet to HA on page 7. small Elimination diet trial, RIGHT DIAGNOSIS

RESPONSE

RESPONSE TOP ® ( Continue diet NO RRHE PURSUE Endoscopy/laparotomy IA GO TO Endoscopy/laparotomy Bowel Diarrhea Bowel See also S Distinguishing DRM DermatologicalDRM Management FortiFlora EN GastroentericEN HA HypoallergenicHA D chronic PURINA VETERINARY DIETS *

* DIARRHEA chronic small bowel 21

, OUT

RESPONSE

RULE or olsalazine NO Anthelmintics, HA, FortiFlora Specific therapy, Specific ± corticosteroids ± specific therapy, therapy, specific food allergy with allergy food change diet to HA corticosteroids, etc, corticosteroids, colitis Antibiotics, FortiFlora, change diet or to EN HA food elimination diet trial, change diet to DCO or OM change diet to or HA DRM Eosinophilic inflammation Lymphoma Neutrophilia Lymphoplasmacytic lgorithms A I G fluoroquinolones ABNORMAL Antibiotics, FortiFlora, Boxer orBoxer similar breed – change diet to DCO or OM Clostridium, Campylobacter Inflammatory cells, Inflammatory neutrophils, histiocytes Antibiotics, FortiFlora, change diet to DCO or OM FortiFlora 4 Fluoroquinolones, Antibiotics, FortiFlora change diet to or HA DRM, Neutrophilia CAT – TT CAT DOG – Histiocytic Boxer orBoxer similar breed Parasites Anthelmintics ABNORMAL biopsy RESPONSE

Colonoscopy, fecal flotation, Giardia ELISA, NO Perform diet PE, history, fecal MDB, cytology,

RESPONSE

Empirical anthelmintics NORMAL NO

FortiFlora

Canine EN, HA,EN, DRM, ®

Canine & Feline bowel ® Nonspecific diet therapy, diet Nonspecific

mall From Large From mall RESPONSE Canine NORMAL ® * change diet to HA Canine & Feline ® Elimination diet trial, Canine & Feline A ® on page 7. large

® RESPONSE Continue diet RRHE IA Bowel Diarrhea Bowel See also S Distinguishing OM OverweightOM Management DRM DermatologicDRM Management DCO Dual Fiber Control FortiFlora EN GastroentericEN HA HypoallergenicHA D chronic PURINA VETERINARY DIETS *

* DIARRHEA chronic large bowel 22

G I A lgorithms GO TO PAGE 18 TOGO PAGE GO TO PAGE 27 TOGO PAGE DIAGNOSIS

GO TO PAGES 25 & 26 TOGO PAGES GO TO PAGES 20, 21, 22 TOGO PAGES ANOREXIA ALGORITHM VOMITING ALGORITHMS VOMITING DIARRHEA ALGORITHMS WEIGHT LOSS ALGORITHM WEIGHT Weight loss?Weight Other signs? GI PURSUE Perform diet PE, history FortiFlora IMPROVEMENT

NO change diet to DCO or OM, Try moderateTry fiber formula, s u m g y Highly digestibleHighly No other signs GI change diet to EN ® o r low fiberlow food, FortiFlora,

Canine & Feline ® Canine ® CE / Bo / rb CE Canine & Feline N IMPROVEMENT ® Continue & FortiFlora EN ® ULE AT OM OverweightOM Management DCO Dual Fiber Control FortiFlora EN GastroentericEN FL chronic PURINA VETERINARY DIETS

FLATULENCE / Borborygmus chronic 23

DIAGNOSIS DIAGNOSIS

dental disease, upper respiratory diarrhea infection, neoplasia PURSUE PURSUE Oral disease foreign body, neoplasia GO TO PAGES 25 & 26 TOGO PAGES GO TO PAGES 20, 21, 22 TOGO PAGES lgorithms VOMITING ALGORITHMS VOMITING DIARRHEA ALGORITHMS GI disease,GI vomiting, Upper respiratory signs respiratory Upper A ABNORMAL I G Tumor oral exam Foreign body Persistent RAA Perform diet PE, history, ABNORMAL OUT

RULE hiatal hernia megaesophagus, Remove foreign body Foreign body strictures, inflammation, NORMAL ± contrast± Esophageal changes Esophageal ABNORMAL Thoracic radiographs radiographs Thoracic NORMAL ENDOSCOPY * 4 OUT

NORMAL RULE cTSH, TT ITATION on page 7. myasthenia, Addison’s (rare), hypothyroidism (rare) ACh receptorACh antibody test, stimulation, ACTH Regurgitation Distinguishing Vomiting From From See also Vomiting Distinguishing REGURG dysphagia *

* REGURGITATION dysphagia 24

OUT

T – fPLI 4 virus T A G T toxins

OUT

I RULE A RULE paracentesis thyroid) lgorithms r T – panleukopenia UA, blood pressure, UA, DOG – parv o lymphocytosis ultrasound, ± biopsy Bile acids,Bile abdominal Abdominal ultrasound, C A ultrasound, urine culture ACTH stimulationACTH Urine P:CREA,Urine complete DOG C – cPLI, T – increased (hype Leukopenia Increased lipase, A C Increased K, decreased Na, inflammatory leukogram inflammatory Increased enzymes liver Increased BUN/CREA ABNORMAL 4 T T

® T – A C Perform diet PE, history, able MDB, fecalMDB, exam, Canine & Feline ® on page 7. y when s t & biopsy Endoscopic or Endoscopic Decompression, surgical removal surge r Exploratory surgeryExploratory DOG – GDV Foreign body Regurgitation Distinguishing Vomiting From From See also Vomiting Distinguishing EN GastroentericEN PURINA VETERINARY DIETS * Mass, intussusception ABNORMAL

OUT

RULE dietary indiscretion NORMAL GO TO PAGE 26 TOGO PAGE as needed as Continue EN OUT Primary abdominal GI

RESPONSE

CHRONIC VOMITING ALGORITHM VOMITING CHRONIC change diet to EN RESPONSE radiography and/orradiography ultrasound NO RULE Anthelmintic therapy, therapy, Anthelmintic Nonspecific drugs, toxins drugs, * gastroenteritis parenteral fluids Change diet to EN dietary indiscretion, Parasites (occult) Withhold food 12 to H, 24 NORMAL Vomitin g acute

* Vomiting acute 25

4 paracentesis urine culture change diet to EN GI ± biopsy, acids, bile

pressure, ultrasound,pressure, Urine P:CREA,Urine blood Abdominal ultrasound Abdominal ultrasound, ACTH stimulationACTH lymphocytosis (hyperthyroid) Increased lipase, Increased CAT – increased T Increased BUN/CREA Increased enzymes liver inflammatory leukogram inflammatory Increased K, decreased Na, SECONDARY lgorithms

® A I ABNORMAL G

Canine & Feline ® Canine & Feline ® on Page 7. , heartworm Ag 4 & biopsy OUT anemia

Endoscopic or Endoscopic surgical removal Hematemesis, Exploratory surgeryExploratory RULE Change diet to EN CAT – T test, endoscopy, gastrin Foreign body chronic pancreatitis ACTH stimulation,ACTH coagulation Regurgitation Distinguishing Vomiting From From See also Vomiting Distinguishing EN GastroentericEN HA HypoallergenicHA PURINA VETERINARY DIETS * Mass, intussusception ABNORMAL Perform diet PE, history, fecal MDB, exam GI

CAT – fPLI CAT infections NORMAL Change diet to HA PRIMARY or ultrasound Inflammatory lesions, Inflammatory RESPONSE

abdominal radiograph abdominal NO DOG – cPLI, Contrast radiography, endoscopy, surgery, biopsy surgery, endoscopy, Change diet to EN Nonspecific gastroenteritis Motility disorder Motility modifiers RESPONSE Continue EN NORMAL * Obstruction Surgery & biopsy & Surgery Parasites (occult) Anthelmintic therapy Anthelmintic Vomitin g chronic

* Vomiting chronic 26

4 T OUT OUT

G PLE liver diseaseliver , change diet to HA I RULE RULE , A DOG – insulin, UPC change diet to HA PLN change diet to DM Hyperthyroid change diet to DCO Endoscopy, biopsy Endoscopy, lgorithms APPETITE proteinuria

CAT – oral hypoglycemic,CAT CAT – Elevated T CAT lymphopenia Blood pressure, ultrasound, biopsy, Hypoalbuminemia, Hypoalbuminemia, Hypoalbuminemia, hypocholesteremia, ABNORMAL GO TO PAGE 18 TOGO PAGE Hyperglycemia, glucosuria REDUCED PURSUE DIAGNOSIS ANOREXIA ALGORITHIM ® 4

Appetite? OUT CAT – T fecal exam

Feline ® Adequate diet Perform diet PE, history Canine PLE ® Perform MDB, PE, RULE Endoscopy & biopsy & Endoscopy NO DM DietaryDM Management DCO Dual Fiber Control PURINA VETERINARY DIETS Poor diet NORMAL GI signs? GI Change to premium diet / APPETITE

YES NORMAL INCREASED Adequate calorie intake? Diet history? Exercise level? Diarrhea? Vomiting? Change to Change energy-dense diet Increased exercise GO TO PAGE 26 TOGO PAGE GO TO PAGE 20 TOGO PAGE VOMITING ALGORITHM DIARRHEA ALGORITHM oss t l food intake gh Consider calorie-dense diet i (RER) & increase Calculate food needs e Inadequate calorie intake W

Weight loss

Purina Veterinary Diets® for GI Support

COMBINED CANINE & FELINE

® ■ DCO Dual Fiber Control Canine...... 29

® ■ DM Dietetic Management Feline...... 29

® ■ EN Gastroenteric Canine...... 30

® ■ EN Gastroenteric Feline...... 30

® ■ HA Hypoallergenic Canine...... 31

® ■ HA Hypoallergenic Feline...... 31

® ■ NF Kidney Function Canine...... 32

® ■ NF Kidney Function Feline...... 32

® ■ OM Overweight Management Canine...... 33 * ® For information about Purina Veterinary Diets, call ® ■ OM Overweight Management Feline...... 33 the Veterinary Resource Center at 1-800-222-VETS ® ■ DRM Dermatologic Management Canine...... 34 (8387) weekdays, 8:00 am to 4:30 pm CT, or visit

® our website at PurinaVeterinaryDiets.com. ■ FortiFlora ...... 34

Dual Fiber Control® DCO Canine Formula

CLINICAL CONSIDERATIONS The role of dietary management in canine diabetes mellitus and colitis is to provide a proper balance of total nutrients while meeting the special dietary needs of the patient. Complex carbohydrates and dietary fiber help to delay the absorption of glucose from the intestinal tract and minimize postprandial fluctuation of glucose in dogs with diabetes mellitus. Soluble fiber in the diet may also prolong gastrointestinal transit time, allow greater water absorption and promote the production of short-chain fatty acids, which nourish the intestinal mucosa.

DIET CHARACTERISTICS • Complete and balanced nutrition for • Targeted urine pH-acid (6.0–6.2) • Source of omega-3 and omega-6 maintenance of adult dogs • Increased fiber, including soluble fiber fatty acids • High level of complex carbohydrates • Moderate total dietary fat and calories

MEDICAL INDICATIONS • Diabetes mellitus • Fiber-responsive colitis • Constipation • Large bowel diarrhea MEDICAL CONTRAINDICATIONS • Conditions associated with catabolic states

Dietetic Management®

DM Feline Formula Diets P urina Veterinary

CLINICAL CONSIDERATIONS The role of dietary management in feline diabetes mellitus is to provide a proper balance of nutrients while meeting the special dietary needs of the patient. Cats are unique in their requirement to metabolize high concentrations of dietary protein. A high percentage of protein is used for gluconeogenesis. The increased concentration of high-quality protein in this diet provides the cat’s essential amino acid requirements and a substrate for glucose production. With glucose production from dietary amino acids, the carbohydrate content of the diet may be dramatically reduced, as with this formulation. Glucose derived from hepatic gluconeogenesis is delivered to the bloodstream at a slower rate compared to the release of glucose from digestion of dietary carbohydrate. The result is a more consistent, steady release of glucose and the potential for reduced insulin requirements.

DIET CHARACTERISTICS • Complete and balanced nutrition for the • High protein • Low carbohydrate ®

adult cat • Source of omega-3 and omega-6 • High level of antioxidants G I S upport fatty acids MEDICAL INDICATIONS • Diabetes mellitus • Critical care management of cats • Enteritis, diarrhea • Persistent hyperglycemia and dogs

MEDICAL CONTRAINDICATIONS • Renal failure • Hepatic encephalopathy

Gastroenteric® EN Canine Formula

CLINICAL CONSIDERATIONS The role of dietary management in canine gastrointestinal conditions is to provide a proper balance of total nutrients while meeting the special dietary needs of the patient. Dietary fats from long-chain triglycerides (LCTs) can be one of the most complex nutrients to digest, and fermentation of undigested fats can contribute to diarrhea. Medium-chain triglycerides (MCTs) provide a readily digested and utilized energy source. Feeding a properly formulated diet designed to be highly digestible yet restricted in long-chain triglycerides may be beneficial in the management of certain gastrointestinal conditions while meeting the nutritional needs of the animal.

DIET CHARACTERISTICS • Complete and balanced nutrition • Moderate fat • Increased antioxidant vitamins E and C for growth of puppies and maintenance • Source of omega-3 and omega-6 • Added zinc of adult dogs fatty acids • Source of MCTs (22% to 34% of fat) • High digestibility • Low fiber

MEDICAL INDICATIONS • Enteritis, gastritis and diarrhea • Hyperlipidemia • Lymphangiectasia • Pancreatitis • Inflammatory bowel disease (IBD) • Hepatic disease not associated • Exocrine pancreatic insufficiency (EPI) • Malabsorption and maldigestion with encephalopathy

MEDICAL CONTRAINDICATIONS • None

Gastroenteric® EN Feline Formula

CLINICAL CONSIDERATIONS The role of dietary management in feline gastrointestinal conditions is to provide a proper balance of total nutrients while meeting the special dietary needs of the patient. Some cats with diarrhea are sensitive to dietary carbohydrates. Feeding a high-quality diet that is high in protein and low in carbohydrates provides optimal nutrition for these cats with compromised gastrointestinal tracts. With added B vitamins,

G I S upport easily absorbed chelated minerals and high fat content, EN provides the nutrients needed to help support cats with GI tract problems. ® DIET CHARACTERISTICS • Complete and balanced nutrition • Added B vitamins • Chelated minerals (copper, zinc, for growth of kittens and maintenance • High protein manganese) of adult cats • Exceptional palatability • Moderate fat • Low carbohydrate

MEDICAL INDICATIONS • Enteritis • Diarrhea • Hepatic lipidosis • Gastritis • Vomiting

MEDICAL CONTRAINDICATIONS • Renal failure • Hepatic encephalopathy urina Veterinary P urina Veterinary Diets

Hypoallergenic® HA Canine Formula

CLINICAL CONSIDERATIONS The role of dietary management in canine food allergy is to provide a proper balance of total nutrients while meeting the special dietary needs of the patient. Most common food allergens are proteins with a molecular weight of 18,000 to 70,000 daltons. Protein modification is a process that alters the physical characteristics of protein molecules, reducing the antigenicity and rendering them less able to elicit an immune response. By reducing the molecular weight of the protein molecule below 18,000 daltons, this process can result in a protein that is truly hypoallergenic.

DIET CHARACTERISTICS • Complete and balanced nutrition • Single protein source • Vegetarian diet for growth of puppies and maintenance • Source of medium-chain triglycerides • Low-allergen carbohydrate source of adult dogs (MCTs), 23% of fat • Hydrolyzed protein source (average • High digestibility molecular weight below 12,200 daltons)

MEDICAL INDICATIONS • Elimination diet for food trials • Gastroenteritis associated with food • Inflammatory bowel disease (IBD) • Dermatitis associated with food allergy allergy • Lymphangiectasia • Pancreatitis • Exocrine pancreatic insufficiency (EPI) • Malabsorption • Protein-losing enteropathy (PLE) • Hyperlipidemia MEDICAL CONTRAINDICATIONS • None

Hypoallergenic®

HA Feline Formula Diets P urina Veterinary

CLINICAL CONSIDERATIONS The role of dietary management in feline food allergy is to provide a proper balance of total nutrients while meeting the special dietary needs of the patient. Most common food allergens are proteins with a molecular weight of 18,000 to 70,000 daltons. Protein hydrolysis is a process that reduces the protein size to small polypeptides, reducing the antigenicity and rendering them less able to elicit an immune response. By reducing the molecular weight of the protein molecule below 18,000 daltons, this process can result in a protein that is truly hypoallergenic.

DIET CHARACTERISTICS • Complete and balanced nutrition • Hydrolyzed protein with a low • High digestibility for growth of kittens and maintenance molecular weight of adult cats • Low allergen carbohydrate source ® G I S upport MEDICAL INDICATIONS • Elimination diet for food trials • Food intolerance • Inflammatory bowel disease (IBD) • Gastroenteritis associated • Dermatitis associated with food allergy with food allergy • Chronic nonspecific diarrhea and vomiting

MEDICAL CONTRAINDICATIONS • None

Kidney Function® NF Canine Formula

CLINICAL CONSIDERATIONS The role of dietary management in canine kidney conditions is to provide a proper balance of total nutrients while meeting the special dietary needs of the patient. Low phosphorus intake helps to protect against hyperphosphatemia and associated renal damage. Restricted but high-quality protein in the diet minimizes the intake of nonessential amino acids. This helps decrease the production of nitrogenous waste products. Reduced levels of sodium help compensate for the diseased kidney’s inability to regulate this important mineral. Increased omega-3 fatty acids may help reduce glomerular hypertension.

DIET CHARACTERISTICS • Complete and balanced nutrition • Reduced protein • Target urine pH-alkaline (6.7–7.5) for maintenance of adult dogs • Added potassium • Source of omega-3 and omega-6 • Low phosphorus • Reduced sodium fatty acids

MEDICAL INDICATIONS • Renal failure • Early stages of congestive heart failure • Hepatic disease associated with • Calcium oxalate urolithiasis encephalopathy

MEDICAL CONTRAINDICATIONS Conditions that require high protein or phosphorus intake

Kidney Function® NF Feline Formula

CLINICAL CONSIDERATIONS The role of dietary management in feline kidney conditions is to provide an appropriate balance of total nutrients while meeting the special dietary needs of the patient. Low phosphorus intake helps to protect against hyperphosphatemia and the associated renal damage. Restricted but high-quality protein in the diet minimizes the intake of nonessential amino acids. This helps decrease the production of

G I S upport nitrogenous waste products. Reduced levels of sodium help compensate for the diseased kidney’s inability to regulate this important ® mineral. Increased omega-3 fatty acids may help reduce glomerular hypertension.

DIET CHARACTERISTICS • Complete and balanced nutrition • Source of omega-3 and omega-6 • Added potassium for maintenance of adult cats fatty acids • Reduced protein • Low phosphorus • Target urine pH-alkaline (6.7–7.5) • Added B-complex vitamins • Reduced sodium

MEDICAL INDICATIONS • Renal failure • Hepatic disease associated • Early stages of congestive heart failure with encephalopathy

MEDICAL CONTRAINDICATIONS • Conditions that require high protein or phosphorus intake urina Veterinary P urina Veterinary Diets

Overweight Managment® OM Canine Formula

CLINICAL CONSIDERATIONS The role of dietary management in canine obesity is to reduce calorie intake sufficiently to induce weight loss, while providing a proper balance of total nutrients. A low fat diet can be helpful in controlling calorie intake. Dietary crude fiber helps reduce the amount of available calories and contributes to satiety. Increased dietary protein increases metabolic activity and may promote satiety. In addition, an increased protein:calorie ratio promotes loss of body fat while helping to minimize the loss of lean body mass during weight loss. Obese animals experience an increase in oxidative stress. Isoflavones have been shown to reduce oxidative stress in overweight dogs. Isoflavones also aid in weight maintenance by helping to reduce weight rebound and the associated accumulation of fat. Feeding a diet that is low in calories, high in protein and fiber, and that contains isoflavones, may be beneficial in the management of obesity while meeting the nutritional needs of the animal.

DIET CHARACTERISTICS • Complete and balanced nutrition for • Low fat • High protein:calorie ratio weight loss and weight maintenance of • Low calorie • Target urine pH-acid (6.2–6.4) adult dogs • High fiber • Contains a source of isoflavones (dry)

MEDICAL INDICATIONS • Fiber-responsive colitis • Neutered/spayed dogs • Constipation • Hyperlipidemia in overweight dogs • Diabetes mellitus in overweight dogs • Obesity

MEDICAL CONTRAINDICATIONS • Conditions associated with catabolic states

Overweight Managment®

OM Feline Formula Diets P urina Veterinary

CLINICAL CONSIDERATIONS The role of dietary management in feline obesity is to provide a proper balance of total nutrients while meeting the special dietary needs of the patient. Dietary fats contribute more than twice the available energy compared to carbohydrates and protein. A low fat diet can be helpful in controlling calorie intake. Dietary crude fiber is poorly digested and helps reduce the amount of available calories and may contribute to satiety. Increased dietary protein may promote both increased metabolic activity and satiety. In addition, an increased protein:calorie ratio promotes loss of body fat while helping to minimize the loss of lean body mass during weight loss. Feeding a properly formulated diet designed to be restricted in calories, and high in fiber and protein, may be beneficial in the management of obesity while meeting the nutritional needs of the animal.

DIET CHARACTERISTICS • Complete and balanced nutrition for • Low fat • High fiber ®

weight loss and weight maintenance • Promotes acidic urine • High protein:calorie ratio G I S upport of adult cats • Low calorie

MEDICAL INDICATIONS • Obesity • Diabetes mellitus in overweight cats • Constipation • Fiber-responsive colitis • Hyperlipidemia in overweight cats • Hairballs

MEDICAL CONTRAINDICATIONS • Conditions associated with catabolic states

Dermatologic Managment® DRM Canine Formula

CLINICAL CONSIDERATIONS The role of dietary management in canine atopy, dermatitis and other inflammatory skin conditions is to provide a proper balance of total nutrients while meeting the special dietary needs of the patient. Nutritional management of dermatitis involves providing nutrients that can support healthy skin and help to reduce the production of inflammatory mediators. Essential fatty acids, key vitamins and amino acids, and trace minerals such as zinc are critical to healthy skin. Long chain omega-3 fatty acids have been shown to reduce the inflammation and clinical signs associated with atopy and allergic dermatitis, so may be beneficial in these and other inflammatory skin conditions. A diet with novel protein ingredients may also help in the management of dogs with food allergies.

DIET CHARACTERISTICS • Complete and balanced nutrition • High omega-3 fatty acid content • Increased antioxidant vitamins A, E for growth of puppies and maintenance • Appropriate levels of omega-6 and beta-carotene of adult dogs fatty acids • Added zinc • Limited number of novel protein MEDICAL INDICATIONS ingredients • Atopy • Other inflammatory skin conditions • Food allergy dermatitis • Pruritus

MEDICAL CONTRAINDICATIONS • Allergies to listed ingredients

® FortiFlora Nutritional Supplement

CLINICAL CONSIDERATIONS Gastrointestinal tract conditions such as diarrhea are commonly seen in dogs and cats and are often associated with an imbalance in the intestinal microflora. Restoring microflora balance is a key component of the effective management of these conditions. FortiFlora is a nutritional supplement that contains a probiotic, Enterococcus faecium strain SF68, for the dietary management of dogs and cats

G I S upport with diarrhea. This probiotic has been shown to be safe, stable and effective in restoring normal intestinal health and balance. ® DIET CHARACTERISTICS • Contains a guaranteed level of viable microorganisms • Shown to be safe for use in dogs and cats • Proprietary microencapsulation process for enhanced stability • Contains high levels of antioxidant vitamins A, E and C • Proven to promote normal intestinal microflora • Excellent palatability • Promotes a strong immune system

MEDICAL INDICATIONS • Diarrhea associated with microflora imbalance • Acute enteritis • Diarrhea associated with stress, antibiotic therapy • Poor fecal quality in puppies and kittens and diet change • Compromised strong immune system

MEDICAL CONTRAINDICATIONS • Dogs and cats with food allergies urina Veterinary P urina Veterinary Diets • Severely immune-compromised dogs and cats

34 Quick Resource Guide Diagnosis and Dietary Management of Gastrointestinal Disease

VET 2229B-0711 Trademarks owned by Société des Produits Nestlé S.A., Vevey Switzerland Printed in the U.S.A.