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Bleeding at both ends: hemorrhagic gastroenteritis is scary, but responds to fast treatment.

The symptoms came on fast and furious. One day Chloe was a healthy, tail-wagging Labrador Retriever and the next day she was vomiting mucus all over the house. Then her vomit turned red with blood and then came matching diarrhea. Chloe had hemorrhagic gastroenteritis, or HGE.

Hemorrhagic gastroenteritis is a mystery disease. No one knows what causes it and there is no recommended prevention. It does not seem to be contagious from one dog to another, although dogs living together sometimes develop HGE at the same time, and some parts of the country have reported outbreaks of several cases. It's most dangerous for small dogs, and although some veterinarians consider toy and miniature breeds between the ages of two and four the most typical HGE patients, males and females of all breeds and ages have been affected.

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There are few, if any, HGE warning signs. It is not usually accompanied by a fever. Diarrhea containing bright or dark red blood is the illness's signature symptom. Vomiting, which usually accompanies the diarrhea, typically begins as mucus or bile and then becomes bloody. Affected dogs may eat grass and vomit that as well.

Because HGE can be fatal, prompt veterinary care is essential. Patients are not usually dehydrated when first examined, but dehydration can develop quickly, leading to hypotension (low blood pressure), an elevated red blood cell count, shock, blood clotting problems, or kidney failure.

Confirming the diagnosis

Hemorrhagic gastroenteritis is usually diagnosed by a process of elimination, since there are several other disorders that produce bloody vomiting and diarrhea.

Puppies and young dogs may develop these symptoms after eating slippers, leashes, or other foreign objects. Dogs of all ages can bleed from trauma injuries; the ingestion of toxic substances or contaminated food; gastrointestinal ulcers; colitis; infectious diseases such as parvovirus and coronavirus; infections from Campylobacter, Salmonella, Clostridium, Escherichia coli, and Leptosperosis bacteria; parasites such as whipworms, hookworms, cocciodiosis, and giardia; warfarin (rat poison); coagulation disorders; gastrointestinal cancer; and Addison's disease (hypoadrenocorticism).

Because a comprehensive examination with complete blood count (CBC), biochemical profile, urinalysis, fecal examination, and bacterial cultures is both expensive and time-consuming, unless a specific cause can be quickly identified, such as a swallowed foreign object or parvovirus, the diagnosis is likely to be HGE.

In addition to producing diarrhea that looks like raspberry jam, canine patients appear tired and weak. Many have an elevated pulse and labored breathing.

Treatment

The treatment of HGE may or may not involve hospitalization, but it often includes the administration of fluids to prevent dehydration. Without sufficient fluids, the blood thickens and its flow through blood vessels may be impeded.

For patients treated early, subcutaneous fluids or even plain drinking water may be sufficient, but intravenous fluids are recommended to prevent "disseminated intravascular coagulation," or DIC, a potentially fatal clotting disorder that occurs when the blood thickens and slows. Once DIC has begun, it is often irreversible.

Although HGE has not been shown to be caused by bacterial infections, parasites, fungal infections, viruses, or any other specific pathogens, many veterinarians prescribe medications that address these agents. In addition, patients may be given medications that treat ulcers, soothe the gastrointestinal tract, or prevent nausea, vomiting, or pain.

The patient's veterinarian may recommend that no food or water be given by mouth for one to four days to let the digestive system rest or that water be given in small amounts every few hours the first day and then in larger amounts as long as it doesn't contribute to nausea and vomiting. Food is reintroduced slowly. A veterinarian may recommend that a new or different type of protein is fed to the dog in case the problem was related to the dog's previous diet. Alternatively, a prescription pet food may be used until the acute phase of HGE has passed.

Seasonal and regional?

Two weeks before Chloe's symptoms began, she and I moved from New York to Helena, Montana. At 7 p.m. on a Monday in May, she vomited blood, and I drove her to the first veterinarian listed in the phone book who could see us. I used a plastic bag to gather a sample some of the bloody mucus that she vomited to show to the vet.

Heidi Wampler, DVM, took one look at Chloe and the bag of mucus and said, "This looks familiar." Chloe's pulse was fast but her temperature was normal, and when Dr. Wampler removed the thermometer, a pool of bright red diarrhea came with it.

According to Dr. Wampler, dogs in the Helena Valley present these symptoms in spring and fall, when the ground is damp from snow melt or rain. She and her colleagues have tested affected dogs for the bacterial, viral, and parasitic infections listed above, and when dogs in multiple-pet households developed symptoms at the same time, as two dogs in a five-dog household did recently, they tested soil and water samples.

"But no matter what we test for," says Dr. Wampler, "we can't find a cause."

When I spoke with Chloe's previous veterinarian, Stacey Hershman, DVM, in Hastings-on-Hudson, New York, she said, "Hemorrhagic gastroenteritis is common in the spring in the Northeast, too. I have treated five dogs in the past two months. There is usually no known cause, and we give supportive care with subcutaneous or IV fluids and medications like metronidazole, which works well against anaerobic bacteria and parasites such as giardia, just in case they're involved."

In the winters of 2004, 2005, and 2006, outbreaks of mild to moderately severe bloody diarrhea in dogs were reported to the Los Angeles County (California) Veterinary Public Health office. Because so many cases occurred near each other within a short time, researchers suspected that a contagious infection or food contamination caused the illness. However, extensive diagnostic tests conducted during each outbreak failed to reveal a connection.

In January 2009, the L.A. County Veterinary Public Health department reported a much higher than normal incidence of canine diarrhea and hemorrhagic gastroenteritis in the San Fernando Valley. They began collecting information about the diet and lifestyle of affected animals as well as the results of their physical exams, laboratory tests, and treatment protocols.

The department's report explained, "If parvovirus is considered a possibility, a rapid in-clinic test on feces may be done first to make sure that is not the problem.

Fecal tests for parasites are often performed. Blood tests often show that the dog has a very high red blood cell count and low protein levels as protein and fluid are lost into the gut. Sometimes additional tests such as fecal cultures are done, or radiographs of the abdomen are taken to check whether the dog has swallowed any unusual objects."

Between January 1 and February 12, 2009, veterinarians at 13 Los Angeles County clinics reported 99 cases of bloody or watery diarrhea in dogs. Most of the patients (82) also had vomiting. Half recovered within five days and half took longer to recover or had a waxing and waning disease course. At least 29 cases required intravenous fluid treatment, while others required less intensive care. Most cases were treated with antibiotics and anti-nausea or anti-vomiting drugs.

No evidence links this disease outbreak to January's recall of peanut butter products contaminated with Salmonella. Of the 12 Los Angeles County dogs with HGE who were checked for Salmonella, all tested negative. Tests for several other infectious agents were also performed but none were conclusive. There is no evidence that any food contamination played a role, because the affected dogs ate a wide variety of foods.

In almost 90 percent of cases reported, no other pet in the house had the same illness. HGE does not appear to spread easily from dog to dog, and it does not appear to spread from dogs to people.

Whether HGE is a regional or seasonal illness remains speculative, but there does seem to be a connection in at least some parts of the country between HGE and certain times of the year.

In general, HGE strikes anywhere at any time. In most parts of the United States, it is a random rather than seasonal disorder.

And it's rare. If you've never heard of hemorrhagic gastroenteritis, you're not alone. Even at its peak, the Los Angeles County outbreak affected less than a fraction of one percent of the county's 1.9 million canines. But if your dog is one of its victims, HGE is an enormous problem.

Canine patients

Janet Tobiassen Crosby, DVM, has treated only one dog for HGE, and that was during her first year of veterinary practice. However, dozens of dog lovers across the country have described their pets' bouts with HGE at her Veterinary Medicine Blog and online forums.

The patients' breeds include Jack Russell Terrier, Beagle, Pembroke Welsh Corgi, Labrador Retriever, Pit Bull, Toy Fox Terrier, Miniature Dachshund, Golden Retriever, English Bulldog, Miniature Poodle, Miniature American Eskimo, Yorkshire Terrier, English Springer Spaniel, Maltese, Miniature Schnauzer, Bichon Frise, Shih Tzu, Chihuahua, Silken Windhound, and several mixed breeds.

Their stories illustrate the frustration, confusion, fear, and loss that HGE produces, for many of these dogs were desperately ill and some of them died. If the reports share a common message, it's a plea for fast action.

"Time is of the essence," agrees Dr. Crosby. "Because there are so many possible causes of vomiting or diarrhea, the best thing you can do is call your veterinarian immediately. HGE has a high survival rate when patients receive aggressive support therapy, and a pet that has observant caretakers (the situation just happened and they responded right away) has a much better chance than pets that have been sick for days. It also helps if the dog is in good health to begin with and at a good weight. Age can be a factor, too, with young to middle-aged dogs bouncing back faster. Like other illnesses, HGE is hardest on pets that are in poor shape to begin with."

One HGE survivor whose story appears on Dr. Crosby's forum is Helios (Ch. Talisman's Light of Helios SRC IC), a Silken Windhound with racing and coursing titles who lives in Walnut Creek, California, with Joyce Chin. In May 2008, when he was one and a half years old, Helios became lethargic and vomited bloody foam.

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"He wasn't interested that morning in playing with the pups," says Chin, "and he's always playing with the pups. Since he's always so happy and on the go, it was a dramatic change. He developed bloody diarrhea and was in the vet clinic on IV fluids and 1V antibiotics for almost a week. He's better now and has regained the weight he lost, but he really could have died. I'm so glad we were around to catch it. It would have been very hard to lose him, he's such a happy part of the family here. When he was in the hospital, all the hounds were looking for him."

Hospital stays can be expensive. Just ask Heidi Hansen, who lives in San Anselmo, California, with her eight-year-old, 100-pound yellow Lab, Herbie.

"Herbie's HGE symptoms started at about 5 a.m. on a Sunday last April," she says, "and by 9 a.m. he was in the hospital. He stayed there for three days and needed albumin transfusions. The total bill came to $5,620."

Fortunately, Herbie survived his ordeal. "He's better now," says Hansen, "but he's slower than before. This took a lot out of him. He had blood loss once before, so he has had a tough time."

Looking for culprits

So far, the cause of hemorrhagic gastroenteritis has eluded everyone, but the search goes on.

Enterotoxigenic Clostridium perfringens is the most commonly suspected agent in HGE cases because specific strains of Clostridium have been associated with hemorrhagic gastroenteritis in both dogs and cats. This common inhabitant of soil, air, dust, and manure is found in the water of lakes, streams, and rivers, and it is a contaminant in many types of commercially prepared foods.

Toxins associated with Clostridium bind to the intestinal epithelial cells of infected animals, increasing membrane permeability. However, since Clostridium is a normal inhabitant of the intestinal tract, no one knows whether it's involved.

Some veterinarians suspect that allergies may play a role, but no one has been able to find a specific allergen that has caused HGE in any patient.

Is diet a factor? Some veterinarians and Internet resources blame raw food, home-prepared diets, and "people food" for HGE, but the evidence doesn't support those claims, either. Most HGE patients have eaten commercial pet food all their lives. This doesn't mean that diet isn't a factor, but it's one that hasn't been proven.

"One common contributing factor," says Dr. Crosby, "may be stress or hyperactivity. I wonder if this might help explain why smaller dogs are over-represented."

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The stress theory makes sense to me. For a month before we moved, Chloe lived with packing boxes and confusion. Her morning routine was interrupted when I tripped on a log while hiking and broke my right wrist. Thanks to friends, the packing got done, but I wasn't able to drive, take Chloe for hikes, or prepare her usual dinners. We switched to a dehydrated food for convenience, and she did well on it as she has in the past while traveling or staying with friends.

After the moving van departed, my fiance, Stephen, drove us 2,300 miles with Chloe and Pumpkin (a red tabby cat) on my car's back seat. Waiting for us in Helena was our new roommate, a Cairn Terrier. Seamus is a sweet dog but he guards food and toys. While Chloe gets along with everyone, settling into her new home made May a stressful month.

And while HGE doesn't seem related to pathogens, I can't help but notice a coincidence of timing. For most of her life, Chloe has consumed one or two tablespoons of coconut oil every day, a supplement whose medium-chain fatty acids help destroy viruses, harmful bacteria, parasites, yeast, and fungi. She also received probiotics, which are the body's first line of defense against many agents of infection, along with supplements that improve digestion and the assimilation of nutrients. But during and immediately after our move, I forgot or was at best inconsistent. When Chloe's immune system most needed a boost, it wasn't getting one.

Because a small number of dogs develop HGE more than once, one of my goals is to protect Chloe from future episodes. Even though the HGE experts say there is no way to do this, anything that strengthens her immune system sounds like a good idea! Stress relief is another strategy we'll employ to keep her healthy. The passage of time and a comfortable daily routine are already helping to reduce Chloe's stress.

Home support

Not all HGE patients are hospitalized and not all of them need IV or subcutaneous fluids. Dr. Wampler sent Chloe home with medication and instructions to call during the night if she continued to vomit or if her symptoms grew worse. In her favor, Chloe was five years old, athletic, and otherwise healthy.

Dr. Wampler warned us that Chloe would probably have diarrhea without realizing it and that we might want to confine her to keep things tidy. I put layers of towels in Chloe's crate and changed them twice during the night when they became soaked. Owners who describe how they discovered their dogs in what looked like a slaughterhouse or excecution scene aren't exaggerating. HGE can be a huge and malodorous mess.

That night we gave Chloe small amounts of water but no food.

According to Small Animal Clinical Nutrition, a veterinary textbook edited by Michael S. Hand, et al, the best foods for patients with acute vomiting and diarrhea are those that do not produce "excess dietary acid load." Foods that normally produce alkaline urine are less likely to be associated with acidosis than foods that produce acid urine. Grains are alkalizing foods, while meat is acidifying. As a result, according to this theory, foods that are high in grain may be more comfortable than meat-based diets for dogs with gastrointestinal distress.

Another theory is that high-fiber foods, such as canned foods prescribed for dogs with diabetes, may be helpful during the acute phase of HGE. Dr. Wampler give us four cans of a high-fiber prescription food to help Chloe make a comfortable transition back to solid food.

Her appetite came back the next morning but she vomited the small amount she swallowed and lost interest in food for the rest of the day. The towels in her crate didn't need to be changed, but she released alarmingly red diarrhea in the backyard. The one encouraging sign was her thirst, for she drank increasingly large amounts of water that stayed down.

By Wednesday, 48 hours after her first symptoms, Chloe's appetite was back and she was on the mend. By Friday, she was her tail-wagging self again, producing normal bowel movements and ready for hiking. She was delighted to resume her regular diet and has been thriving ever since.

Keeping HGE in perspective

Hemorrhagic gastroenteritis is a serious illness, but most dogs will never develop its symptoms. Still, because it progresses so quickly and is potentially dangerous, being able to recognize those symptoms and act on them can mean the difference between life and death. If your dog- or any dog- is bleeding from both ends, don't wait. Get immediate help. With rapid treatment the story should, like Chloe's, have a happy ending.

What you can do ...

* Pay attention to your dog's symptoms, especially vomiting or diarrhea.

* If you see blood, don't wait. Call your veterinarian immediately.

* If you live in an are known to have HE outbreaks, be especially vigilant.

* Do what you can to keep your dog's immune system strong. It can't hurt and Might help.

Resources Mentioned in This Article

Janet Tobiassen Crosby, DVM, vetmedicine.about.com

Heidi Wampler, DVM. Alpine Animal Clinic, Helena, MT. (406)449-7155, alpineanimalclinic.com

Stacey Hershman, DVM. Natural Vet for Pets, Hastings-on-Hudson, NY. (914)478-4100, naturalvetforpets.com.

Los Angeles County Veterinary Public Health Department. (877)747-2243, publichealth.lacounty.gov/vet

Small Animal Clinical Nutrition, edited by Michael S. Hand, et al. Mark Morris Institute; 4th Edition, 2000.

CJ Puotinen is a freelance writer and a longtime contributor to WDJ. She is also author of many books on holistic health, including Natural Remedies for Dogs and Cats. She recently moved to Helena, Montana from New York. For contact and book purchasing information, see "Resources," page 24.
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Title Annotation:dog diseases
Author:Puotinen, C.J.
Publication:Whole Dog Journal
Geographic Code:1USA
Date:Jul 1, 2009
Words:3096
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