Protein Losing Enteropathy in Dogs (PLE)
Dr. Bari Spielman
A complete blood count (CBC) may be within normal limits but may reveal anemia (low red blood cell count), and in cases of lymphangiectasia, a decreased lymphocyte (type of white blood cell) count.
Certain diagnostic tests must be performed to make a definitive diagnosis of the underlying disorder and to exclude other disease processes that may cause similar symptoms. A complete history, description of clinical signs, and thorough physical examination are all an important part of obtaining a diagnosis. In addition, the following tests are recommended to confirm a diagnosis:
A biochemical profile can help evaluate the kidney, liver, protein, and electrolyte status. Hypoproteinemia is the hallmark of this group of diseases. Hypocalcemia (low calcium) is often seen secondary to low protein levels. Additionally, in cases of lymphangiectasia, hypocholesterolemia (decreased cholesterol) is common.
A urinalysis is most often within normal limits, and is helpful in ruling out protein loss associated with kidney disease. If there is any suspicion of kidney related protein loss, a urine protein:creatinine ratio should be evaluated. It is a simple test that can be performed on the urine.
Fecal examinations should be performed to rule out parasitism. Chest and abdominal X-rays, although often within normal limits, may be of benefit in ruling out other disorders.
Abdominal ultrasound may be indicated if the previous diagnostics have been inconclusive. It helps to evaluate the size, shape and integrity of the abdominal organs, and is especially helpful in evaluating for an intussusception or pancreatitis. It is a non-invasive procedure, although it may require a referral facility.
An upper gastrointestinal (GI) barium series may be considered to help rule out foreign bodies that can be seen on X-ray and other causes of intestinal blockage. It also helps evaluate for intestinal ulcers, and can assess intestinal wall thickness. A safe dye is given to the pet by mouth and is watched as it travels through the GI tract. It is non-invasive and most often able to be performed by your veterinarian, although sometimes it may necessitate a referral facility.
Gastroduodenoscopy is often indicated. This test allows direct visualization of the stomach and the duodenum by means of an endoscope that is passed through the mouth and esophagus into the stomach. With this procedure, biopsies can be obtained without an abdominal incision and submitted for microscopic evaluation. General anesthesia is necessary, but endoscopy is considered a relatively low risk procedure. It most often necessitates the expertise of a specialist and specialized instrumentation.
Your veterinarian may require additional tests to insure optimal medical care. These are selected on a case by case basis:
Serum folate and cobalamin are blood tests, which generally increase and decrease respectively, in those cases with small intestinal bacterial overgrowth (SIBO).
Cytologic examination of feces and the rectal tissue may reveal histoplasmosis.
Cardiac ultrasound may be performed in those patients where heart disease is felt to play a part in the hypoproteinemia.
Laparotomy, which is an incision into the abdominal, allows surgical biopsies of intestines, lymph nodes, and other organs to be obtained. Laparotomy is not recommended unless all prior procedures are inconclusive, and/or the patient is not responding well to appropriate therapy. There are moderate risks associated with doing surgery on hypoproteinemic animals, and should be performed only if absolutely necessary.
Appropriate therapy for protein losing enteropathy is largely dependent on the underlying cause, and varies according to the type and severity of clinical illness. Depending on the severity of clinical signs and/or stage of disease, hospitalization may or may not be recommended. Patients who have severe vomiting and/or diarrhea, dehydration, or hypoproteinemia and associated inappropriate fluid accumulation are hospitalized for aggressive treatment and stabilization. Stable patients can be treated as outpatients as long as they are monitored closely for response to therapy. With appropriate therapy, many patients do quite well. It is important that all recommendations by your veterinarian are followed very closely, and any questions or concerns that arise during treatment are addressed immediately.
Dietary management is often recommended and varies on the underlying cause. For lymphangiectasia, low fat diets are recommended. For gluten-induced enteropathy, diets with no gluten (wheat, grains) are recommended. For immune-mediated inflammatory bowel disease, easily digestible and/or non-allergenic diets are recommended. For lymphoplasmacytic enteritis, easily digestible and/or non-allergenic diets are recommended.
MCT oil is a source of calories that is well tolerated by patients with PLE (specifically, lymphangiectasia) that may be indicated in patients who are severely emaciated.
Fluid therapy may be necessary in some patients with severe vomiting and/or diarrhea, and is directed toward correction of dehydration and acid-base derangements, replacement of electrolyte deficits, and to provide for ongoing losses.
Diuretics to help remove excess fluid from the body may be indicated in some patients with PLE.
Oncotic agents (plasma, dextran, hetastarch) are products that help maintain normal fluid distribution in the body.
Antibiotic therapy, anti-inflammatory drugs, and/or antifungal agents may be indicated depending on the underlying cause.