Peer Reviewed

GI Intervention
Approach to Diagnosis
and Therapy of the
Patient with
Acute Diarrhea
P. Jane Armstrong, DVM, MS, MBA,
Diplomate ACVIM

D
iarrhea can be defined as increased fecal fluidity, • There was a positive association between occurrence of
usually accompanied by increased defecation fre- diarrhea and vomiting in the same dog, but episodes of diar-
quency and volume of feces. Most cases of diarrhea rhea and vomiting did not usually occur at the same time.
are mild and self-limiting, requiring minimal diagnostics • Diarrhea and vomiting had a much higher frequency
and therapy. Life-threatening cases can occur, however, in young puppies despite complete vaccination and
that require greater diagnostic efforts and intensive care. deworming protocols.
• Risk for diarrhea decreased from 16% in 7-to-12-week-
ACUTE VERSUS CHRONIC old puppies to 5.4% in 12-to-18-month-old dogs.
Diarrhea is considered:1 An early study showed that frequency of both vomiting and
• Acute if it lasts for less than 14 days diarrhea were highest in puppies and declined with increas-
• Chronic if it persists for longer than 14 days. ing age4; this is supported by Banfield data demonstrating
Historical and clinical findings and appearance of the that “gastroenteritis (GI upset)” was common in dogs up
feces are used to differentiate whether the diarrhea is of to 3 years but much less common in dogs above that age.2
small bowel or large bowel origin (Table 1). This differen-
tiation is most important in cases of chronic diarrhea, when OWNER IDENTIFICATION
selection of diagnostic tests is influenced by the presumed Diarrhea is generally recognized by owners, as long as the
location of enteric pathology. Additionally, many pets with feces are observed. Most owners realize that diarrhea is
acute diarrhea display signs of enterocolitis (mixed small usually self-limiting and may be more prone to “wait and
and large bowel signs). see” when pets develop gastrointestinal (GI) signs, com-
pared to clinical signs that are not as familiar.
PREVALENCE & INCIDENCE In a study of 772 pet dogs in England, 70% of the reports
While diarrhea is a very common presenting problem in of diarrhea involved only 1 or 2 episodes, and 78% lasted 2
companion animal practice, it is either more common in days or less. Veterinary attention was sought for only 10%
dogs than cats, or dogs with diarrhea are more likely to of dogs with diarrhea (and 5% of vomiting dogs).5 All dogs
be examined by a veterinarian. A report of diagnoses from with diarrhea persisting for 7 days or longer were presented
over 2 million dogs and almost 430,000 cats in 2011 indi- to a veterinarian.
cated that “gastroenteritis (GI upset)” and “colitis” both
ranked in the top 19 diagnoses for dogs, but were not PATHOPHYSIOLOGY
among the most common diagnoses in cats.2 Four major pathophysiologic mechanisms can cause diar-
Incidence of diarrhea and vomiting was investigated pro- rhea. Osmotic forces and changes in mucosal permeabil-
spectively in a Norwegian study of 585 large-breed dogs ity are the most important mechanisms in dogs and cats.
followed from birth to 2 years of age.3 In most small animal diseases, multiple mechanisms con-
• Most dogs had only one episode of diarrhea and/or tribute to diarrhea, and it can be difficult to determine the
vomiting during the study period; those suffering from predominant mechanism.
several episodes demonstrated relatively long periods 1. Osmotic diarrhea: The number of osmotically active
between episodes. particles in feces determines water content, and pres-

20 Today’s Veterinary Practice May/June 2013

 GI Intervention: Patient with Acute Diarrhea |

Tremendous fluid loss can occur when the

Table 1. Findings Used to Differentiate Small Bowel small and/or large intestine are not functioning
From Large Bowel Diarrhea normally. Mild diarrhea causes few metabolic
consequences; however, moderate or severe diar-
FINDING SMALL BOWEL LARGE BOWEL rhea can lead to profound dehydration, hypovo-
Frequency of Normal to mildly Markedly increased lemic shock, electrolyte abnormalities (hypoka-
defecation increased lemia, hypochloremia, and hyponatremia), and
Fecal volume Normal to increased Decreased acid–base disturbances.
Fecal mucus Absent Often present Metabolic acidosis typically develops secondary
to loss of intestinal bicarbonate and dehydration
Fecal blood Melena Hematochezia
leading to hypovolemia, anaerobic metabolism by
Tenesmus Absent Often present tissues, and production of lactic acid.
Urgency Absent Often present
Dyschezia Absent Often present ACUTE DIARRHEA: CAUSES
Vomiting May be present Infrequently present There are many causes of acute diarrhea in dogs
and cats (Table 2, page 22). In many cases of
Weight loss Often present Infrequently present
acute diarrhea, signs resolve spontaneously or
Steatorrhea May be present Often present with symptomatic therapy without a specific
cause being discovered.
ence of increased numbers of these particles within the In animals with chronic diarrhea, a thorough
intestinal lumen leads to osmotic diarrhea. diagnostic evaluation and appropriate dietary and thera-
peutic trials for diagnostic purposes are much more impor-
Osmotic diarrhea occurs with many malabsorptive
tant. It is beyond the scope of this review to discuss causes
disorders, such as exocrine pancreatic insufficiency,
and diagnostic approach to pets with chronic diarrhea;
in which poorly digested nutrients are malabsorbed,
however, watch for evidence of chronicity even at first pre-
remain within the GI lumen, and attract water. It can
sentation of a pet with diarrhea.
also occur with overeating and dietary indiscretion if
poorly absorbed nutrients are ingested.
Endoparasites
Retention of nutrients in the GI tract can also lead
It is well documented that endoparasitism is primarily a
to dysbiosis (see below) and fermentation of carbohy-
concern in young animals.2,6-8 Batchelor, et al, documented
drates, which further increases the number of osmoti- that dogs with GI signs had a higher prevalence of intesti-
cally active particles. A hallmark of osmotic diarrhea is nal parasites, including Giardia and Toxocara.6 In a refer-
that it resolves when the patient stops ingesting poorly ral population, however, dogs with GI signs had no greater
absorbable solute. odds of endoparasitism than healthy animals; instead, age
2. Secretory diarrhea: Stimulation of crypt enterocytes and median household income were the strongest predic-
results in secretion of large volumes of fluid that exceeds tors of endoparasitism, and dogs from heavily populated
the absorptive ability of the intestine. This occurs most ZIP codes had the greatest risk for endoparasitism.9
commonly with infectious diseases, such as enteropatho-
genic Escherichia coli and salmonellosis, but is also a Dietary Indiscretion
mechanism of diarrhea related to inflammatory bowel Dietary indiscretion is a common cause of acute diar-
disease (IBD). By-products of dysbiosis can also stimulate rhea. One study reported that feeding a home-cooked
intestinal secretion. One distinguishing feature of secre- diet, recent history of scavenging, or change of diet all
tory diarrhea is its persistence despite fasting, which is increased the risk for diarrhea in dogs.10 Another study
due to abnormalities in ion transport not related to food. found a positive correlation between development of diar-
3. Increased mucosal permeability: Increased perme- rhea and/or vomiting and reports of scavenging behavior
ability of the intestinal mucosa causes loss of fluids, elec- (stealing food; eating trash; or eating feces from horses,
trolytes, proteins, and blood into the intestinal lumen. farm animals, or cats).5 No correlation was found between
It commonly accompanies erosive, ulcerative, neoplastic GI signs and eating table food.
(intestinal lymphoma), and inflammatory processes,
such as IBD and hookworm infection. Bacterial Enteritis
4. Abnormal motility: Deranged motility is often secondary A variety of bacteria are known or suspected to cause enter-
to disorders that cause diarrhea. Decreased segmental con- itis in dogs and cats (Table 2). Establishing a diagnosis of
tractions result in transport of ingesta at a rate too fast for bacterial enteritis creates a significant challenge due to:
normal digestion and absorption. Platelet-activating factor, • Limitations in understanding the complex intestinal
synthesized and released from several immunocytes, may microflora
be one of the inflammatory response mediators that stimu- • Inadequate investigation of many potential pathogens.
lates giant aboral contractions, the powerful contractions The fact that the microorganisms responsible for enter-
that propagate—uninterrupted—from the small intestine itis can be found in healthy individuals, and may not be
to the ileum or colon. found at a higher prevalence in animals with diarrhea,

May/June 2013 Today’s Veterinary Practice 21

| GI Intervention: Patient with Acute Diarrhea

confounds diagnosis, treatment decisions, and

Table 2. Differential Diagnosis of Acute Diarrhea assessment of infection control and zoonotic risk
(Table 3, page 25).
SELF-LIMITING LIFE-THREATENING Cytology. Microscopic examination of fresh
Dietary Indiscretion Bacteria feces has been used by some clinicians for pre-
• Chemicals and toxins • Campylobacter species sumptive diagnosis of disease by evaluating patho-
• Diet change • Clostridium difficile toxins gen appearance. However, fecal cytology is now
• Foreign material A/B considered of no diagnostic utility for bacterial
• Garbage or table scraps • Clostridium perfringens enteropathogen identification because:
• Plants enterotoxin
• These bacteria can be present in normal animals
• Enteropathogenic E coli
• Salmonella species • Appearance does not differentiate between patho-
• Yersinia species genic strains and harmless commensal species
• In the case of Clostridium perfringens, no stud-
Drugs Systemic Diseases
• Antibiotics • Acute liver disease ies have reported a correlation between pres-
• Cancer chemotherapeutics • Acute pancreatitis ence or number of spores and signs of disease.
• Copper chelators • Acute renal failure Enterotoxin has received the most attention in
• Corticosteroids (leptospirosis) relation to C perfringens, and some association has
• Digoxin • Canine distemper been found between the presence of C perfringens
• Magnesium antacids • Hypoadrenocorticism enterotoxin (CPE) and diarrhea in dogs.11
• Nonsteroidal anti- • Salmon poisoning
Intestinal Microbes. Intestinal microbes play a
inflammatory drugs
crucial role in maintenance of host health. They:
Parasites Intestinal Obstruction • Act as a defending barrier against transient
• Coccidia, including • Foreign body pathogens
Cryptosporidium species • Intestinal accident
• Giardia • Intussusception • Support the host in digestion and energy har-
• Hookworms, roundworms, vest from the diet
and whipworms • Stimulate the immune system
Other Other
• Provide nutritional support for enterocytes.
• Acute colitis • Hemorrhagic The total microbial load in the intestine is esti-
• Clostridium perfringens gastroenteritis (see Box) mated at 1012 to 1014 organisms, about 10× the num-
enterotoxin • Canine parvovirus and ber of host cells in the entire body.
• Coronavirus feline panleukopenia New technologies have enhanced our under-
• Idiopathic • Severe dietary indiscretion standing of the microorganisms harbored by mam-
• Severe parasitism
malian GI tracts. Massive parallel 16S rRNA gene
(hookworms and
whipworms) pyrosequencing has provided the tool for molecu-
lar-phylogenetic characterization of the GI tract’s
Adapted, with permission, from Leib MS, Munroe WE (eds): Practical Small Animal
Internal Medicine. Philadelphia: WB Saunders, 1997, p 692. complex microbial community.12 The gene con-
tent of these microbes is defined as the intestinal
microbiome.
There is mounting evidence that changes in
Hemorrhagic gastroenteritis (HGE) is a diarrheal microbial populations play an important role in
syndrome of unknown etiology that has a predilection pathogenesis of acute and chronic enteropathies
for small breed dogs; it has not been reported in cats. of dogs. In a recent study, dogs with acute diar-
Speculation regarding pathogenesis includes type-1 rhea, especially those with acute hemorrhagic diar-
hypersensitivity reaction to food components, CPE, and C rhea, had the most profound alterations in their
difficile toxins A/B. fecal microbiome compared to healthy dogs, and
HGE is distinctively characterized by peracute onset of observed changes differed between acute and
bloody diarrhea and vomiting accompanied by marked chronic disease states.13
hemoconcentration. Packed cell volume of an affected dog Recognition of fecal biome alterations (dysbiosis)
can reach 75% or higher within hours of onset of signs, yet in pets with various GI disorders opens the door
total plasma protein often remains within reference range. to future studies that evaluate the ability of probi-
Symptomatic therapy, primarily aggressive IV fluid otics, prebiotics, antibiotics, and other therapies to
therapy and gastroprotectants, results in marked clinical restore the balance of bacterial flora.
improvement within 24 to 48 hours. Antimicrobial therapy
is usually administered, although in a recent study, clinical ACUTE DIARRHEA: HISTORY & PHYSICAL
response was not improved in dogs that received antibiotics EXAMINATION
(amoxicillin/clavulanic acid).14 With appropriate therapy, Signalment and history often contain the infor-
mortality is low despite severity of signs. mation necessary to make a tentative diagnosis or
help rank differential diagnoses (Tables 1 and 2).

22 Today’s Veterinary Practice May/June 2013

 GI Intervention: Patient with Acute Diarrhea |

Puppies and kittens, especially from shelters, are prone to Laboratory Analysis.
viral diseases and GI parasites. Measuring total plasma
Physical examination may detect: protein and hematocrit
• Abdominal masses • Dilated loops of bowel will help assess hydration
• Foreign bodies • Intussusception and provide a baseline for
• Abdominal pain. reference if clinical signs
When patient size permits, routinely performing digital persist or progress.
rectal palpation aids recovery of feces for observation of the
presence of blood (digested [melena] or fresh) and/or mucus. Symptomatic Therapy
Dehydration (at least 5% to be clinically noted) may be • If dietary indiscretion
evident by dry mucous membranes, loss of skin turgor, has occurred, removal
Figure. Photomicrograph of fecal cytol-
prolonged capillary refill time, or enophthalmos. More of the incriminating ogy showing sporulated organisms
pronounced alterations in these parameters indicate mod- factors and/or feeding compatible with Clostridium perfringens.
erate dehydration (7%–9%); extreme alterations denote a highly digestible diet Fecal cytology, however, is not con-
severe dehydration (10%–12%) approaching hypovolemic for 3 to 5 days usually sidered to be diagnostically useful for
shock (tachycardia with poor peripheral perfusion and helps resolve diarrhea. bacterial enteropathogen identification.
weak peripheral pulses). • If parasites are detect-
ed, diarrhea should improve 2 to 3 days after appropri-
ACUTE DIARRHEA: DIAGNOSTICS ate treatment
The most important initial step in evaluating animals with • If an etiology is not found, a presumptive diagnosis of
acute diarrhea is to determine if they have a self-limiting acute idiopathic self-limiting diarrhea may be made.
or potentially life-threatening problem (Table 2). This dis- Symptomatic therapy usually relieves clinical signs in 1
tinction is crucial as it guides the level of diagnostics and to 3 days. If diarrhea persists or other clinical signs develop
therapy indicated, and should be based on a thorough his- or intensify, a more serious problem may exist, requiring
tory, careful physical examination, clinical experience and thorough evaluation and more intensive therapy.
judgment, and a sound understanding of the differential
diagnoses for acute diarrhea. Additional Diagnostics
Laboratory Analysis. Laboratory evaluation helps rank
Initial Diagnostics differential diagnoses as well as assess severity of dehydra-
Fecal Flotation. Animals with suspected self-limiting diar- tion and electrolyte disorders; it may include:
rhea should always be tested for GI parasites by centrifuga- • Complete blood count
tion fecal flotation using zinc sulfate, paired with indirect • Serum biochemistry profile
fluorescent antibody testing for Giardia cysts and Crypto- • Urinalysis
sporidium oocysts. • Baseline cortisol (to exclude hypoadrenocorticism)
Cytology. Fecal cytology, a low-yield diagnostic test, is • SNAP Parvo Test (idexx.com).
not useful for detection of potential bacterial enteropatho- In chronic or recurrent cases of diarrhea, serum concen-
gens (Figure). In contrast, exfoliative rectal cytology can be trations of cobalamin and folate and canine or feline tryp-
useful in dogs and cats with signs of colitis, especially when sin-like immunoreactivity (cTLI or fTLI) can be measured.
chronic, to identify fungal organisms or colonic neoplasia. Depending on clinical signs, patients may be evaluated for
hyperthyroidism (cats) and pancreatitis.
A patient may have a potentially LIFE-
Radiography. Survey abdominal radiographs may dem-
THREATENING PROBLEM if some of the following onstrate an abdominal mass, dilated loop of bowel, ileo-
are present: colic intussusception, foreign body obstruction, or linear
• Moderate to severe dehydration foreign body requiring surgical intervention.
• Abdominal pain Specific Identification. Additional diagnostic tests may
• Depression be indicated to definitively diagnose a specific organism or
• Melena or hematochezia disease or to pursue diagnosis if a cause is not yet evident
• Presence of an abdominal mass or dilated loop of (eg, abdominal ultrasound).
bowel • Identification of Tritrichomonas foetus; several diagnos-
• Frequent vomiting tic tests are available
• Signs of systemic illness, such as: • Serologic testing for feline leukemia and immunodefi-
• Ascites • Lymphadenopathy
ciency viruses may be warranted in diarrheic cats based
• Coughing • Ocular and nasal discharge
on housing and origin
• Hepatomegaly • Oliguria/anuria
• Partial analysis for enteric pathogens, usually reserved
• Icterus • Pyrexia
If the distinction is not clear cut, it is better to be for diarrheic pets that are systemically ill or in contact
cautious and initially manage the patient as if it has a with an immunosuppressed person:
life-threatening problem. »» Fecal enteric panel: Gram-stained fecal smear, CPE
enterotoxin enzyme-linked immunosorbent assay

May/June 2013 Today’s Veterinary Practice 23

| GI Intervention: Patient with Acute Diarrhea

Table 3. Potential Enteric Bacterial Pathogens in Dogs & Cats

ORGANISM Prevalence ANTIBIOTIC CHOICE IF THERAPY APPEARS INDICATED
Campylobacter Healthy: Dogs, 21%–76% Enrofloxacin: Dogs, 5 mg/kg PO Q 12 H
Cats, 16%–58% Cats, 2.5 mg/kg PO Q 12 H (or marbo-
Diarrheic: Dogs, 60%–97% floxacin to avoid risk of retinal damage)
Cats, 16%–31% Alternatives: Tylosin, tetracycline, or erythromycin
C perfringens Healthy: Dogs, 11%–100% Usefulness of treatment unknown for mild cases;
Diarrheic: Dogs, 27%–86% consider treatment of severe (HGE) or chronic diarrhea
with metronidazole or tylosin; alternatives are
ampicillin or amoxicillin-clavulanic acid
C difficile* Healthy: Dogs and cats, 0%–10% Metronidazole: See Table 4, page 55
Diarrheic: Data not available
Salmonella Healthy: Dogs, 0%–2.9% No indication to treat healthy carriers. Use of
Cats, 0.4%–1.7% antimicrobials is controversial except in cases of
Diarrheic: Data not available systemic illness (bacterial translocation); treat based on in
vitro susceptibility testing.
*Infections in pets appear to be community-acquired, not hospital- or antibiotic-associated, as in human patients.
Weese JS. Bacterial enteritis in dogs and cats: Diagnosis, therapy, and zoonotic potential. Vet Clin Small Anim 2011; 41:287-309.
Marks SL, Rankin SC, Byrne BA, Weese JS. Enteropathogenic bacteria in dogs and cats: Diagnosis, epidemiology, treatment, and control. J Vet Intern Med
2011; 25:1195-1208.

(ELISA), C difficile toxin A/B ELISA • Such diets for dogs should have a low or modest fat con-
»» Fecal culture or polymerase chain reaction (PCR): For tent; fat restriction is not required for cats.
potential bacterial pathogens, such as Salmonella and • Useful choices include boiled rice with lean chicken,
Campylobacter low-fat cottage cheese, or tofu; Prescription Diet i/d Low
It is very difficult to establish evidence for a causal asso- Fat GI Restore (hillsvet.com); Purina Veterinary Diets EN
ciation between the presence of a specific bacterium in the Gastroenteric (nestlepurina.com); and Veterinary Diet
feces and occurrence of diarrhea (Table 3). Intestinal Low Fat (royalcanin.us).
When diarrhea resolves, the animal’s usual diet can be
ACUTE DIARRHEA: MEDICAL THERAPY slowly reintroduced over a 2- to 3-day period by adding
Most cases of self-limiting diarrhea resolve within 1 to 5 25%, 50%, 75%, and finally 100% of the usual diet. If vom-
days, following correction of the underlying cause and/or iting is concurrently present, an antiemetic can be admin-
symptomatic treatment. istered.
Nonspecific symptomatic therapy may include one or High-fiber diets. For pets with signs of acute large bowel
more of the following: diarrhea (Table 1), a high-fiber diet is often used instead
• Nutritional management of a bland diet as fiber may be beneficial in reducing tenes-
• Therapeutic deworming mus and facilitating colonic epithelial repair. Commercial
• Antidiarrheal
• Antiemetic and/or gas-
troprotectant A recent British study documented the prescribing habits of veterinarians for
• Probiotic dogs with acute diarrhea seen in general practice.15 A total of 371 dogs of various
• Antimicrobial (selected breeds, ages, and sexes were represented. See Box for study results.
cases) THERAPY USE IN CASES
• Fluid therapy.
Antibacterials 71%
Nutritional Management Probiotics/antidiarrheal 26%
Administration. Animals Steroids 19%
with acute diarrhea often Antiemetics (vomiting present concurrently) 13%
benefit from withholding Gastric protectants (primarily if vomiting/melena present) 10%
food for 6 to 12 hours fol-
Sulfasalazine (use associated with presence of fecal mucus) 7%
lowed by frequent (3–6
small meals/day) feed- The frequent use of antibacterials for acute diarrhea is surprising and somewhat
ing of small amounts of a alarming. There is evidence that resistance to antimicrobials is increasing among
highly digestible, so-called bacteria isolated from pets.16 Nutritional management, therapeutic deworming, and
“bland,” diet; amount fed probiotic therapy, accompanied in some cases by an antidiarrheal agent, should be
per meal can be slowly considered first-line therapies (Table 4, page 55).
increased.
(continued on page 54)
24 Today’s Veterinary Practice May/June 2013
| GI Intervention: Patient with Acute Diarrhea

(GI Intervention continued from page 24)

products with increased mixed (soluble and insoluble) fiber ous species of Lactobacillus, Bifidobacter, Bacillus, E coli,
are ideal. Soluble fiber (psyllium mucilloid, 1 tsp/10 kg body Streptococcus, and Saccharomyces.
weight) may be added to a bland diet. Mechanism of Action. Both live and dead cells in probi-
otic products can generate beneficial biological responses.
Therapeutic Deworming • Live probiotic cells influence both GI microbiome and
Parasite Identification. If a GI parasite is identified on the immune response.
fecal examination, the appropriate antiparasiticide should • Components of dead cells may have anti-inflammatory
be prescribed. effects in the GI tract.
In many dogs and cats with acute diarrhea, parasitic In the case of live probiotic organisms, bacterial levels in
infection remains a possibility despite negative test results feces disappear within days when supplementation ceases.
because: Clinical Evidence. To date, limited clinical trials with
• Testing is not 100% sensitive probiotics have been performed in dogs and cats with GI
• Not all parasites shed ova continuously. disorders (see Probiotic Studies in Companion Animals,
Antiparasiticide Selection. For these reasons, a good page 56).
therapeutic strategy to consider is administration of a
broad-spectrum dewormer, such as fenbendazole, which Antimicrobial Therapy
is also an excellent choice for treating giardiasis, showing Nonspecific Use. Routine use of antibiotics in cases of
better efficacy and a greater safety margin than metroni- acute uncomplicated diarrhea is strongly discouraged. If
dazole. If a response to therapeutic deworming is seen, a an antibiotic is selected for nonspecific use in such cases,
second course of fenbendazole in 3 months is needed for metronidazole or tylosin is an appropriate choice.
some parasites, such as whipworms. Specific Use. In acute intestinal diseases, antimicrobials
Antidiarrheals are specifically indicated only in animals with:19
Indications. If diarrhea is frequent enough to interfere • Confirmed bacterial infection (eg, positive blood cul-
with the animal’s (or sometimes the owner’s) ability to ture and/or presence of enteropathogenic bacteria on
rest, causes apparent pain or discomfort, or results in fecal culture, along with signs of sepsis)
large fluid losses, an opioid may be given to alter intesti- • Predisposition for bacterial translocation (eg, disruption
nal motility. of intestinal epithelial barrier)
Mechanism of Action. Opioids prolong intestinal transit • Increased risk for sepsis (eg, immunosuppression, por-
time, allowing increased fluid absorption and reduction in tosystemic shunting).
the frequency of diarrhea. They act by: Pets with acute bloody diarrhea of unknown cause are
• Increasing colonic segmentation, fluid absorption, and usually treated with an antibiotic, such as amoxicillin/cla-
anal tone vulanic acid, or monitored very closely because:
• Decreasing propulsive peristaltic contractions and secre- • Ruling out enteric bacterial infection is challenging
tion • Bacterial translocation is a potentially life-threatening
These drugs are particularly effective in patients with complication.
large bowel diarrhea (colitis). Markedly hemorrhagic diarrhea is often interpreted as
Specific Drugs. Diphenoxylate or loperamide is very evidence of a breach of intestinal integrity, justifying use of
effective in reducing frequency of diarrhea. antimicrobials, although no studies document an increased
• Both are available as elixirs, making dosing convenient risk for bacterial translocation or sepsis in these patients.
for small dogs and cats.
• Loperamide is more potent and has faster onset and Fluid Therapy
longer duration of action than diphenoxylate. Administration. An animal’s deficit due to dehydration
• In dogs, both drugs—at recommended doses—are safe can be calculated by multiplying the percent of estimat-
and have few side effects. ed dehydration (from physical examination) times body
• In cats, excitatory behavior can occur, but appears to be weight (kg). Maintenance fluids (44–66 mL/kg/day) should
rare; for this reason, though, these drugs should be used be added to this deficit. Continued losses from diarrhea
with caution in cats. should be estimated and added to the fluid volume admin-
If a toxin or possibly pathogenic bacteria are the sus- istered.
pected cause of acute diarrhea, opioids are contraindicated If mild dehydration is present, a balanced isotonic poly-
because they may increase toxin absorption or time for bac- ionic fluid (lactated Ringer’s) can be administered subcu-
terial proliferation. taneously, but animals with severe dehydration caused by
life-threatening acute diarrhea require intravenous fluid
Probiotics therapy.20
Definition. Probiotics are live microorganisms that, when Further Diagnostics. If diarrhea worsens or other clini-
administered in adequate amounts, confer a health benefit cal signs develop, the animal should be re-evaluated and
on the host (World Health Organization definition). Pro- further diagnostics considered. Any underlying conditions
biotics include a wide variety of organisms, such as vari- should be specifically treated. If further diagnostic testing

54 Today’s Veterinary Practice May/June 2013

 GI Intervention: Patient with Acute Diarrhea |

Table 4. Medications for Acute Diarrhea: Dogs and Cats

MEDICATION NAME DOSAGE
Antidiarrheals
Diphenoxylate (Lomotil, pfizer. Dogs: 0.05–0.2 mg/kg PO Q 6–8 H
com) *Cats: 0.08–0.1 mg/kg PO Q 12 H
Loperamide (Imodium, jnj.com) Dogs: 0.08–0.2 mg/kg PO Q 6–12 H
*Cats: 0.04 mg/kg PO Q 12–24 H
Antimicrobials for Nonspecific Diarrhea
Dogs: 10-15 mg/kg PO Q 12 H
Metronidazole
Cats: 62.5 mg PO Q 12 H
Tylosin 10–15 mg/kg PO Q 12–24 H
Antimicrobials for Dogs or Cats at Risk for Bacterial Translocation
Amoxicillin-clavulanic acid 12.5–22 mg/kg PO Q 12 H
Ampicillin 22 mg/kg PO Q 8–12 H
Broad-Spectrum Parasiticide
Fenbendazole 50 mg/kg PO Q 24 H for 3–5 days
Probiotics: Fortiflora (nestlepurina.com) & Prostora (iams.com)
*Use with caution in cats.

For dosages of antiemetics and gastroprotectants (for diarrhea cases with

concurrent vomiting, hematemesis, and/or melena), see Medications for
Acute Vomiting: Dogs and Cats, available at todaysveterinarypractice.
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rhea treated by early enteral feeding • Dogs and cats frequently develop
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ment than puppies held off food.21 lasts for less than 7 days.
Monitoring. Careful monitoring is • Most cases are mild and self-limiting,
required during fluid therapy. and likely associated with changes to
• Physical examination findings that the intestinal microbiota.
indicated dehydration should grad- • In mild cases, in which there is no
ually improve as the patient is rehy- indication for antimicrobial thera-
drated during the first 24 hours of py, nutritional management, thera-
therapy. peutic deworming, and probiotic
• Hematocrit and total protein should therapy, sometimes in conjunction
decrease. with an antidiarrheal agent, should
• Body weight should be measured be considered.
frequently, as changes accurately • In cases with more severe, some-
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»» After hydration has been reestab- ough and logical diagnostic plan
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treatment. ate therapy. n Summit, NJ, 07901 MAH-ACT-16

May/June 2013 Today’s Veterinary Practice 55

MK 806 Activyl TickPlus 3rdpage Ad.indd 1 15/03/13 2:34 PM
| GI Intervention: Patient with Acute Diarrhea

occurrence of Cryptosporidium and Giardia in dogs during their first

year of life. Acta Vet Scand 2007, 49:22.
Probiotic Studies in Companion Animals 9. Gates MC, Nolan TJ. Risk factors for endoparasitism in dogs:
Dogs with Acute Diarrhea Retrospective case-control study of 6578 veterinary teaching hospital
Kelley, et al. In one study, 31 young adult dogs with cases. J Small Anim Pract 2009; 50:636-640.
10. Stavisky J, Radford AD, Gaskell R, et al. A case-control study of
acute, uncomplicated, nonspecific diarrhea were pathogen and lifestyle risk factors for diarrhoea in dogs. Prev Vet Med
enrolled in an unblinded, randomized prospective 2011, 99:185-192.
study, receiving either Bifidobacterium animalis strain 11. Marks S, Kather E, Kass P, et al. Genotypic and phenotypic
AHC7 (Prostora, iams.com) or placebo for 2 weeks.17 characterization of Clostridium perfringens and Clostridium difficile in
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for the probiotic group (3.9 ± 2.3 vs 6.6 ± 2.7 days). than we thought. Vet Clin Small Anim 2011; 41:261-272.
Hersted, et al. In a double-blinded, placebo- 13. Suchodolski JS, Markel ME, Garcia-Mazcorro JF, et al. The fecal
controlled study, 36 dogs with acute diarrhea or acute microbiome in dogs with acute diarrhea and idiopathic inflammatory
gastroenteritis were randomized to receive a probiotic bowel disease. PLoS One 2012; 7(12):E51907.
cocktail (2 Lactobacilli species and 2 Bacillus species) 14. Unterer S, Strohmeyer K, Kruse BD, et al. Treatment of aseptic dogs
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no difference in duration of vomiting between groups. predominant therapy used in cases of acute diarrhoea in dogs seen in
These study results suggest that probiotic therapy first-opinion practice. Brit Small Anim Vet Congress Proc 2010.
is a rational approach for shortening the duration of 16. Lloyd DH. Reservoirs of antimicrobial resistance in pet animals. Clin
Infect Dis 2007; 45(Suppl 2):148-152.
diarrhea, improving patient comfort in dogs assessed 17. Kelley R, Minikium K, Kiely B, et al. Clinical benefits of probiotic canine-
to have acute, self-limiting diarrhea. Similar studies in derived Bifidobacterium animalis strain AHC7 in dogs with acute
cats have yet to be published. idiopathic diarrhea. Vet Thera 2009; 10:121.
18. Herstad HK, Nesheim BB, L’Abée-Lund T, et al. Effects of a probiotic
Prevention of Diarrhea intervention in acute canine gastroenteritis: A controlled clinical trial. J
Small Anim Pract 2010; 51:34-38.
Probiotics likely have a role in diarrhea prevention, 19. Bybee SN, Scorza AV, Lappin MR. Effect of the probiotic Enterococcus
such as for pets in stressful conditions. Cats and faecium SF68 on presence of diarrhea in cats and dogs housed in an
dogs housed in an animal shelter were studied to animal shelter. J Vet Intern Med 2011; 25:856-860.
determine whether feeding Enterococcus faecium 20. Mensack S. Fluid therapy: Options and rational administration. Vet Clin
SF-68 (FortiFlora, nestlepurina.com) would decrease N Am Small Anim Pract 2008; 38:575-586.
21. Mohr AJ, Leisewitz AL, Jacobson LS, et al. Effect of early enteral
episodes of diarrhea and improve fecal scores.19 nutrition on intestinal permeability, intestinal protein loss, and outcome
Animals in one room were supplemented daily in dogs with severe parvoviral enteritis. J Vet Intern Med 2003; 17:791-
with FortiFlora while controls received a placebo. 798.
The percentage of cats with diarrhea ≥ 2 days was
significantly lower in the probiotic group (7.7% vs
20.7%), suggesting that probiotics may lessen how long
cats have diarrhea. Diarrhea prevalence rates were low P. Jane Armstrong, DVM,
for all dogs so statistical differences were not detected. MS, MBA, Diplomate
ACVIM (Small Animal Inter-
nal Medicine), is a profes-
sor in the Department of
CPE = Clostridium perfringens enterotoxin; ELISA = Veterinary Clinical Sciences
enzyme-linked immunosorbent assay; GI = gastrointesti- at University of Minnesota
nal; HGE = hemorrhagic gastroenteritis; IBD = inflammatory College of Veterinary Medi-
bowel disease; PCR = polymerase chain reaction cine. She is also a member
of the World Small Animal
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Transbound Emerg Dis 2008, 55:99-104. pleted an internship at University of Illinois and
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residency and Master’s degree at Michigan State
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56 Today’s Veterinary Practice May/June 2013