D i a g n o s i s o f Sm a l l I n t e s t i n a l

D i s o rd e r s i n D o g s a n d C a t s
Karin Allenspach, Dr med vet, FVH, PhD, FHEA

KEYWORDS
 Diagnostic workup  Chronic diarrhea  Small intestine  Laboratory tests

KEY POINTS
 A serum albumin concentration of less than 2 g/L is an indicator of poor prognosis in dogs
with inflammatory bowel disease (IBD).
 Cobalamin should be supplemented in all cases with decreased serum cobalamin
concentrations.
 Increased canine pancreatic lipase in dogs with IBD is associated with a worse outcome.
 In cases of suspected intestinal lymphoma, polymerase chain reaction for antigen recep-
tor rearrangements and immunophenotyping by flow cytometry or immunohistochemistry
should be used in conjunction with clinical signs to help establish a diagnosis.
 Evaluation of intestinal biopsies for expression of CD11c using immunofluorescence may
be a helpful diagnostic test for IBD in dogs.
 Genetic testing for mutations in innate immunity receptors is available for German Shep-
herd dogs, and could become a useful test for other breeds of dogs in the future.

INTRODUCTION: DIAGNOSTIC WORKUP OF SMALL INTESTINAL DISORDERS

The last decade has brought numerous advances in our knowledge about the patho-
genesis of chronic intestinal disorders in people, particularly regarding inflammatory
bowel disease (IBD), which comprises Crohn disease and ulcerative colitis. Specif-
ically, the interplay of innate immunity receptors with commensals of the intestinal
microbiome plays an important role in the disease pathogenesis. Molecular studies
have identified specific disbalances in the microbiome of people with IBD. In addition,
genetic polymorphisms that are associated with an increased risk of development of
IBD have been identified. These data promise to be helpful in the development of new
diagnostic options and targeted molecular treatment strategies for IBD. New findings

This article originally appeared in Veterinary Clinics of North America: Small Animal Practice,
Volume 43, Issue 6, November 2013.
Current Funding Sources: Morris Animal Foundation, British Biotechnology and Bioscience
Research Fund, Probiotics Ltd UK, Laboklin GmbH Germany.
Conflict of Interests: None.
Department of Clinical Sciences and Services, Royal Veterinary College, University of London,
Hawkshead Lane, North Mymms, Hatfield AL9 7PT, UK
E-mail address: [email protected]

Clin Lab Med 35 (2015) 521–534

http://dx.doi.org/10.1016/j.cll.2015.05.003 labmed.theclinics.com
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522 Allenspach

in chronic enteropathies in dogs and cats suggest a pathogenesis similar to that in

people with IBD. Recent studies have detected disbalances in expression of innate
immunity receptors (so-called toll-like receptors [TLRs]) in the intestines of dogs
with IBD1,2 that are similar to those seen in people with IBD. The expression of
some of these receptors also has been correlated with severity of clinical disease in
dogs with IBD, which makes it likely that they are causally implicated in the pathogen-
esis.3 In addition, disbalances in the microbiome (so-called dysbiosis) have been iden-
tified using molecular methods in dogs and cats with IBD.4–6 These findings point
toward a pathogenesis of IBD in dogs and cats similar to that in people, even if the
clinical manifestations of these diseases are different. There is hope that similar
advances regarding diagnostic options and new therapeutic modalities will be made
for canine and feline IBD as has been done for IBD in humans.
A thorough history is important in the evaluation of small animal patients exhibiting
signs of intestinal disorder. The first differentiation should be to establish whether the
disease is acute or chronic. Diarrhea, vomiting, dehydration, weight loss, lethargy, and
melena all can be signs of small intestinal disease. The disease is acute if clinical signs
have been present for only a few days. However, if clinical signs persist for more than
3 weeks or are intermittently present for more than 3 weeks, the disease is defined as
chronic.
If the animal has diarrhea, the next step is to determine whether it has small intes-
tinal, large intestinal, or a combination of small and large intestinal diarrhea (Table 1).

Differential Diagnoses for Acute Small Intestinal Diseases

Systemically well
 Dietary indiscretion
 Intestinal parasites (Ancylostoma caninum, Toxocara, Giardia, Tritrichomonas
fetus)

Systemically unwell, abnormal abdominal palpation, severe diarrhea with

hematochezia, melena, and frequent vomiting
 Dietary indiscretion
 Toxicity
 Viral infection (parvovirus, coronavirus, distemper, feline leukemia virus
[FeLV]/feline immunodeficiency virus [FIV])
 Bacterial infection (Salmonella, Campylobacter, Clostridium)
 Intestinal parasites (Giardia, Tritrichomonas)

Table 1
Differentiation of small-bowel and large-bowel diarrhea

Small Large
Volume 111 1
Mucus 111
Frequency 1 111
Tenesmus 111
Dyschezia 1
Weight loss 11 1
Vomiting 1 1
General condition 1

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 Small Intestinal Disorders in Dogs and Cats 523

 Acute pancreatitis
 Intestinal obstruction
 Hypoadrenocorticism (Addison disease)

DIAGNOSTIC WORKUP OF CHRONIC SMALL INTESTINAL DIARRHEA

Once clinical signs persist for more than 3 weeks, additional workup is required to
establish the diagnosis. In chronic cases it is more common for systemic, nongastroin-
testinal problems to cause the signs, and therefore the first diagnostic steps must be
directed at excluding these extragastrointestinal causes.
Causes of Chronic Small Intestinal Disease
Extragastrointestinal (Metabolic) Causes
 Hepatic disease (portosystemic shunt)
 Hyperthyroidism (cats)
 Hypoadrenocorticism (Addison disease) (dogs)
 Renal insufficiency
 Pancreatitis (acute or chronic)
 Exocrine pancreatic insufficiency (EPI)

Gastrointestinal Causes
 Intestinal parasites (Giardia infection, Tritrichomonas infection) (cats)
 Chronic partial obstruction of the small intestine
 Lymphangiectasia
 Neoplasia: lymphosarcoma
 Food intolerance/food allergy
 Chronic enteropathies/IBD
 Eosinophilic enteritis
 Lymphoplasmacytic enteritis

The diagnosis of chronic gastrointestinal causes is one of exclusion, and a full diag-
nostic workup needs to be done first to rule out all known causes of extragastrointes-
tinal inflammation. This workup commonly involves a complete blood cell count,
serum biochemical analysis, urinalysis, and fecal analysis for helminth and protozoal
parasites (Giardia and Tritrichomonas in cats). Further tests are indicated if none of
these tests are abnormal: trypsin-like immunoreactivity to exclude EPI, canine pancre-
atic lipase immunoreactivity (cPLI) to assess the possibility of pancreatitis or pancre-
atic tumors, corticotropin stimulation test or basal cortisol concentration to exclude
hypoadrenocorticism, and cobalamin concentrations to assess the absorptive func-
tion of the distal small intestine. Total thyroxine (T4) and FeLV/FIV infection also should
be assessed in cats. Abdominal ultrasonography will be more helpful than endoscopy
in determining whether the small and/or large intestine is affected and whether there
are mass lesions that need surgical intervention. If the results of these tests do not
determine the cause for the clinical signs and the patient is stable (ie, has a normal
appetite, is not lethargic, there is no or minimal weight loss, the serum protein concen-
tration is normal, and there is no intestinal thickening on diagnostic imaging), a well-
conducted therapeutic trial with an elimination diet or hydrolyzed diet for at least
2 weeks can be performed. If there is no response to a well-conducted dietary trial
within 2 weeks after starting the diet, it is unlikely that the patient is suffering from
food-responsive disease (FRD) (food allergy or food intolerance).7 If the dietary trial
is unsuccessful, antimicrobials (metronidazole, 10–15 mg/kg by mouth twice a day
or tylosin, 10 mg/kg by mouth once to twice a day) for 2 to 3 weeks can be

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524 Allenspach

administered. Intestinal biopsies for histopathology are collected from those patients
that either fail to respond to empiric therapy or have worsening of their clinical signs.
Most patients with chronic enteropathies can be diagnosed by obtaining endoscopic
biopsies, as long as at least 12 to 15 biopsies from the small intestine are taken (Fig. 1).
In rare cases, a diagnosis of lymphoma can be missed if no full-thickness biopsies are
obtained, especially in cats, and if the ileum has not been sampled.

INTERPRETATION OF LABORATORY TESTS TO AID THE DIAGNOSIS OF CHRONIC SMALL

INTESTINAL DIARRHEA
Serum Albumin Concentrations
Dogs
Decreased serum albumin concentration has been described as a negative prognostic
indicator in retrospective and prospective studies of IBD in dogs. Protein-losing enter-
opathy (PLE) accounts for the loss of albumin through the gut mucosa in severely
affected dogs with IBD. PLE in dogs can be associated with severe lymphoplasma-
cytic IBD, intestinal lymphoma, or, rarely, primary lymphangiectasia. In one study of
dogs with IBD, 12 of 80 (16%) dogs had hypoalbuminemia and 4 of 80 (5%) had pan-
hypoproteinemia.8 Seven of 12 dogs with hypoalbuminemia had to be euthanized for
intractable IBD, identifying decreased serum albumin concentration as a major risk
factor associated with a worse outcome. In another recent prospective study of
dogs with IBD, 12 of 58 (21%) dogs initially presented with hypoalbuminemia.7 Of
these 12 dogs, 7 were panhypoproteinemic with severe hypoalbuminemia (mean albu-
min level 11 g/L), and 3 of these dogs eventually had to be euthanized. However, it
must be noted that relatively mild reductions in serum albumin (<2 g/L) previously

Fig. 1. Diagnostic workup for dogs and cats presenting with signs of chronic small intestinal
disease. CBC, complete blood cell count; Chem, serum biochemical profile; EPI, exocrine
pancreatic insufficiency; UA, urinalysis.

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 Small Intestinal Disorders in Dogs and Cats 525

had been associated with an increased risk of refractoriness to treatment. At this level,
most patients will not yet show any clinical signs of hypoalbuminemia, such as ascites,
peripheral edema, or pleural effusion.
Furthermore, another study found that severely hypoalbuminemic dogs that failed to
improve on immunosuppressive doses of steroids were successfully treated with
cyclosporine.9 This finding suggests that early aggressive treatment in hypoalbumine-
mic dogs may potentially decrease mortality rates in severely ill animals. Serum albu-
min concentration also can be used to monitor patients, as improvement of serum
albumin concentrations higher than 2 g/L usually indicates treatment success, even
if clinical improvement can be seen earlier in some cases. It is therefore recommended
to evaluate serum albumin concentrations every 2 to 3 weeks to assess when treat-
ment can be tapered off or discontinued.

Cats
There is not much published information regarding serum albumin concentrations in
cats with chronic intestinal disease. PLE as a clinical syndrome does not exist in cats,
as clinical signs such as ascites and peripheral edema do not usually occur in cats
with hypoalbuminemia caused by intestinal disease. In addition, the hypoalbumine-
mia seen in such cases is usually mild. In cats with IBD, the prevalence of hypoalbu-
minemia ranged from 5% to 24%.10–12 However, there is evidence that cats with
chronic intestinal disease and decreased serum albumin concentrations may have
concurrent pancreatic disease.
In one recent retrospective study, cats with IBD and serum feline pancreatic lipase
(fPLI) concentrations of 2.0 mg/L or higher had a lower median serum albumin concen-
tration than cats with IBD and a normal fPLI.13 However, hypoalbuminemia was not a
negative predictor of survival in this study. Another study found that cats with moder-
ate to severe pancreatitis were significantly more likely to be hypoalbuminemic than
were healthy cats and cats with mild pancreatitis.14
Therefore, hypoalbuminemia in cats with chronic intestinal disease should prompt the
clinician to measure fPLI concentrations and/or to perform abdominal ultrasonographic
examination to determine if there is concurrent pancreatitis. Depending on the severity
of the hypoalbuminemia, the clinician’s approach to treatment might be altered.

Serum Cobalamin Concentrations in Dogs and Cats

Serum cobalamin concentrations should be measured in any small animal patient with
chronic small intestinal disease. Cobalamin absorption is receptor-mediated in the
ileum, and decreased serum cobalamin concentrations are most commonly seen
when this part of the small intestine is affected. However, absorption of cobalamin
also involves intrinsic factor, which in dogs and cats is produced primarily in the
pancreas. For this reason most small animals with EPI have low serum cobalamin con-
centrations (Fig. 2). The author’s group7 has shown recently that serum cobalamin
also is very important for prognosis in dogs with chronic enteropathies. If cobalamin
serum concentration is below the reference interval, the risk for later euthanasia in-
creases by a factor of 10. It is therefore important to supplement dogs with hypoco-
balaminemia while they undergo treatment of IBD, as this “risk of euthanasia” can
be reversed by cobalamin supplementation.

Cats
Serum cobalamin concentration has long been known to be an important negative
prognostic factor in cats with chronic enteropathies.15 The prevalence of decreased
serum cobalamin concentrations in cats with chronic gastrointestinal signs has

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526 Allenspach

Fig. 2. Absorption of cobalamin is a complex process involving several steps. Cobalamin is

released from food protein in the stomach (A) and immediately bound to R-binder proteins
(B). In the proximal small intestine, the cobalamin-R-binder complex is cleaved after diges-
tion of the R-binder by pancreatic proteases (C). Free cobalamin can now bind to intrinsic
factor (IF) (D), the majority of which is secreted by the pancreas in cats and dogs. This
cobalamin-IF complex is subsequently absorbed by specialized receptors in the ileum (E).

been reported to be up to 16.5%.16 In cats, it has also been reported that cobalamin
supplementation can improve clinical signs regardless of the underlying diagnosis,
and even if given as the sole treatment for their disease.15 It is therefore recommended
that cats with chronic intestinal disease are supplemented with cobalamin regardless
of whether a specific cause for the disease can be identified.

Supplementation recommendations for dogs and cats

Supplementation of cobalamin should be given parenterally (subcutaneously) as a
weekly injection for at least 6 weeks. Exact dosages are not reported, as it is a
water-soluble vitamin and cannot be overdosed. For tested recommendations, please
visit the Web site of the Texas GI Laboratory (http://vetmed.tamu.edu/gilab).

Canine Pancreatic Lipase

cPLI has recently become available as a commercial test and is useful in the assess-
ment of pancreatitis in dogs.17 However, cPLI also can be elevated in dogs with
chronic enteropathy. In a retrospective study of 50 dogs with IBD, the author’s group18
evaluated clinical signs, age, serum lipase and amylase activities, albumin and cobal-
amin concentrations, abdominal ultrasonography results, histopathologic review of
intestinal biopsies, management of IBD, and follow-up in dogs with IBD, either with
or without concurrent chronic pancreatitis. Sixteen dogs with increased cPLI and 32
dogs with normal cPLI values were compared. No significant differences were found
for clinical activity score, serum amylase activity, serum lipase activity, serum

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 Small Intestinal Disorders in Dogs and Cats 527

cobalamin concentration, serum albumin concentration, abdominal ultrasonography

scores, and histopathology scores for IBD. There was no difference in the frequency
of steroid treatment between the groups. Dogs with IBD and concurrent elevated cPLI
were significantly older than dogs without elevated cPLI. Moreover, dogs with
elevated cPLI had a higher risk of a poor follow-up score and were significantly
more likely to be euthanized at follow-up. These data show that elevated cPLI in
canine IBD may indicate that a subset of these patients could also have chronic sub-
clinical pancreatitis. In patients that have been diagnosed with IBD and also have
elevated cPLI without overt imaging evidence of acute pancreatitis, it is recommended
to discuss treatment options for IBD that also will treat possible autoimmune pancre-
atitis. The author has had anecdotal success with cyclosporine at 5 mg/kg daily for
8 weeks in such cases.

C-Reactive Protein
C-reactive protein (CRP) is a serum acute-phase protein that can be elevated in many
different diseases. In people with IBD, several calculated indices of clinical activity of
disease incorporate measurements of CRP.19 In dogs, a similar correlation between
the canine IBD activity index (CIBDAI) and serum CRP concentration has been found
in one large study of 58 dogs.20 CRP was elevated in the 28 dogs with CIBDAI scores
greater than 5 (which comprises mild to moderate disease activity) in comparison with
normal dogs, and CRP decreased significantly after treatment.20
In the author’s experience, CRP is not very helpful when assessing dogs with
chronic enteropathies. CRP was measured in 21 dogs with IBD before treatment
and in 18 dogs after treatment.7 CRP was elevated in only 6 of 21 dogs before treat-
ment, and did not correlate with CIBDAI or histologic scoring.
A large percentage of dogs with IBD do not show any elevations in CRP. Interpre-
tation of elevated levels also may be hampered by increases related to diseases other
than IBD.

Fecal a1-Proteinase Inhibitor

Fecal a1-proteinase inhibitor (a1-PI) can be used as a test for dogs in which the clini-
cian suspects PLE although the clinical signs are not yet overtly visible. a1-PI is a
plasma protein similar in size to albumin. If the intestinal mucosal barrier is compro-
mised and loss of protein into the intestinal lumen occurs, a1-PI is lost at approxi-
mately the same rate as albumin. Unlike albumin, however, its proteinase inhibitor
properties protect a1-PI from degradation by intestinal proteases, and can be
measured in feces. The test recently has been validated for dogs.21
Prompt diagnosis of PLE in a patient with IBD is important because hypoalbumine-
mia is a risk factor for negative outcome,7 and the cause should be treated aggres-
sively to improve survival. The a1-PI assay is especially valuable in patients with
intestinal disease that have concurrent renal or hepatic disease. In these patients,
measurement of fecal a1-PI can help assess which portion, if any, of the protein
loss can be attributed to the intestine. This test is available only at the Texas GI Lab-
oratory. Ideally, 3 consecutive fresh fecal samples should be submitted to improve
test accuracy, which means that fecal a1-PI is not a useful test for practitioners outside
North America.

Histology and World Small Animal Veterinary Association (WSAVA) Scoring of

Intestinal Biopsies
Sampling of intestinal biopsies is an essential step in the evaluation of small intestinal
disorders, to exclude neoplastic causes and confirm the presence of intestinal

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528 Allenspach

inflammation. However, interpretation of intestinal biopsies is difficult and subject to

controversy. In several recent studies looking at conventional histologic interpretation
of intestinal biopsies, there was no correlation between clinical activity and histologic
grading either before or after therapy.7,20,22 In addition, total lymphocyte counts as
well as the number of infiltrating CD3 cells in the lamina propria cannot be used as
markers for clinical activity of disease, as there is no difference in cell counts before
and after treatment.23 These findings suggest that the type and degree of histologic
infiltrates in canine IBD may not be as helpful as in human medicine, in which clinical
scores correlate very well with histologic grading. Therefore, a new grading scheme
for the histologic interpretation of endoscopically obtained biopsies from dogs and
cats with IBD has recently been published by the WSAVA Working Group.24 The find-
ings in this study suggest that microarchitectural changes seem to be much more
important than cellular infiltrates when assessing histologic severity. However, there
is limited information on how well this new grading system correlates with clinical dis-
ease. In one retrospective study, the interpathologist variability was still very high even
when using the picture guide from the original publication.25 In addition, it is of concern
that the only parameter that correlated with clinical disease was the presence of lym-
phangiectasia and hypoalbuminemia. Further prospective studies are warranted
before the WSAVA scoring can be adopted as a useful tool for clinicians.

PARR in Intestinal Biopsies

The polymerase chain reaction for antigen receptor rearrangements (PARR) amplifies
the highly variable T- or B-cell antigen receptor genes, and is used to detect the pres-
ence of a clonally expanded population of lymphocytes. This test has been advocated
as useful when applied on endoscopically sampled biopsies if a diagnosis of intestinal
lymphoma is suspected but not confirmed by conventional histopathology. In a study
at the Royal Veterinary College, the author prospectively evaluated the accuracy of
PARR for the diagnosis of intestinal lymphoma in biopsies obtained endoscopically
from dogs in a comparison with the gold standard of histopathology and clinical
outcome determined by follow-up information of at least 2 years. Samples from 39
dogs were included. PARR results indicated a clonal expansion in 7 of 36 dogs. How-
ever, these dogs were clinically healthy after dietary treatment 2 years after the endos-
copy, so they clearly did not have lymphoma. The data from this study indicate a
false-positive rate of almost 20% for PARR when performed on endoscopic biopsies.
Another recent study has confirmed these findings, showing that in dogs with IBD,
PARR results showed at least one oligoclonal pattern in 38% of dogs, and an immu-
noglobulin (7 of 47; 14.9%) or T-cell receptor (1 of 47: 2.1%) monoclonal pattern in
17% of dogs.26 The conclusion that a positive PARR test on an endoscopic biopsy
means a diagnosis of lymphoma must therefore be made cautiously in a clinical situ-
ation, and clinical signs, response to treatment, and immunohistochemistry must also
be taken into account.

Perinuclear Antineutrophilic Cytoplasmic Antibodies

Perinuclear antineutrophilic cytoplasmic antibodies (pANCA) have been useful in the
diagnosis of human IBD for decades.27 These antibodies are serum autoantibodies
similar to antinuclear antibodies (ANA), but seem to be more specific for intestinal dis-
ease than for ANA. pANCA are detected by immunofluorescence by visualizing a
typical pattern of perinuclear staining.
In the first study to assess the clinical usefulness of pANCA in dogs with IBD, sensi-
tivity for pANCA was 0.51 and specificity ranged between 0.56 and 0.95. pANCA
proved to be a highly specific marker for IBD in dogs when the group of dogs with

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 Small Intestinal Disorders in Dogs and Cats 529

chronic diarrhea of other causes were tested against dogs with IBD (specificity 0.95).28
This finding is in agreement with reports from human medicine that show a specificity
of up to 94% for pANCA when distinguishing between IBD and healthy controls, as
well as patients with non–IBD-related diarrhea from other causes.29 When pANCA
were tested in a group of dogs with FRD and compared with pANCA in dogs with
steroid-responsive disease, a positive pANCA titer was significantly associated with
FRD.30
The pANCA assay might be helpful in differentiating dogs with chronic diarrhea
caused by FRD or IBD: If the result is positive, a food-responsive chronic enteropathy
is highly likely, however, if the result is negative, IBD cannot be excluded.
pANCA also may be associated with the syndrome of familial PLE in soft-coated
wheaten terriers (SCWT).31 pANCA were detectable in the serum of dogs an average
1 to 2 years before the onset of clinical disease, and were highly correlated with hypo-
albuminemia. This test could be a useful screening test for this specific disease in
SCWT.
Care must be taken in interpreting a positive pANCA test result if other inflammatory
or immune-mediated diseases are present. A recent study showed that many dogs
with various vector-borne diseases or immune-mediated hemolytic anemia were
positive for pANCA.32

Calprotectin and S100A12

Calprotectin and S100A12 are calcium-binding proteins that are abundant in the gran-
ules of neutrophils and macrophages. In people with IBD, serum and fecal concentra-
tions of these proteins are increased in comparison with healthy people. In addition,
fecal concentrations of calprotectin correlate very well with clinical disease activity
in children with IBD.33
An immunoassay for measurement of canine calprotectin in serum and fecal sam-
ples is available.34 A serum calprotectin concentration of 296.0 mg/L or higher has
sensitivity of 82.4% and specificity of 68.4% for distinguishing dogs with idiopathic
IBD from healthy dogs. However, calprotectin concentrations were not significantly
correlated with clinical severity, serum CRP concentration, or severity of histopatho-
logic changes. The clinical usefulness of this test needs further evaluation.

Immunohistochemistry for P-Glycoprotein on Intestinal Biopsies

P-glycoprotein (P-gp) is a transmembrane protein that functions as a drug-efflux pump
in the intestinal epithelium. Human patients with IBD who fail to respond to treatment
with glucocorticosteroids express high levels of P-gp in lamina propria lymphocytes.35
Two research groups have evaluated P-gp expression in biopsies of dogs with IBD. In
one study,36 duodenal biopsies from 48 dogs were evaluated by immunohistochem-
istry. Biopsies were evaluated after treatment with prednisolone in 15 dogs and after
dietary therapy alone in 16 dogs. Dogs treated with prednisolone showed significantly
higher P-gp expression in lamina propria lymphocytes after treatment compared with
expression before treatment. By contrast, the group treated solely with an elimination
diet showed no difference in P-gp scores before and after treatment. Moreover, a
statistically significant association between refractoriness to steroid treatment and
high P-gp expression was found in the glucocorticosteroid-treated group.36 In another
recent study, P-gp expression was higher in duodenal epithelial cells of dogs with IBD
compared with healthy control dogs.37 However, there was no difference in P-gp
expression in colonic epithelial cells between IBD and control groups. These results
indicate that epithelial and lamina propria lymphocyte expression of P-gp is upregu-
lated in dogs with IBD, and they are even higher after prednisolone treatment. In

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530 Allenspach

addition, high P-gp expression could indicate possible multidrug resistance and
should be taken into account when managing dogs that have failed steroid treatment
previously.

Immunohistochemistry for CD11c in Intestinal Biopsies

CD11c is a marker of human and murine dendritic cells (DCs), and cells expressing this
marker have been shown to have similar morphologic and functional characteristics in
dogs. DCs are important in determining the outcome of an immune reaction in the gut,
that is, whether a pathogen will elicit a massive immune response or whether a
commensal will induce tolerance.38 Specific subsets of inducible DCs are decreased
in the diseased tissues of people with IBD.39 It is plausible that the number of DCs in
the intestine could be used as a surrogate marker of inflammation in dogs with IBD. In
one recent study, endoscopic biopsies from the duodenum, ileum, and colon were
obtained from dogs with IBD and healthy dogs.40 CD11c expression was assessed
by immunofluorescence using a canine monoclonal antibody (Fig. 3). The number of
CD11c-positive cells in the duodenum, ileum, and colon of dogs with IBD was signif-
icantly reduced in comparison with controls. There was a significant negative correla-
tion between the number of CD11c-positive cells in the colon of dogs with IBD and
clinical severity. This marker therefore holds promise as a useful test to assess histo-
logic samples. However, additional prospective studies are needed to evaluate the
clinical utility of this test.

Genetic Testing
Over the last decade, numerous genes have been associated with an increased risk of
development of IBD in humans, many of them implicated in the innate immune
response in the intestine.41 Dogs with IBD may have a similar genetic component,
especially because there are breeds predisposed to certain forms of IBD. Boxers
are predisposed to histiocytic ulcerative colitis, and German shepherd dogs (GSD)
are predisposed to lymphoplasmacytic IBD.42 The author’s group43 recently per-
formed a mutational analysis of the canine genes for TLR2, TLR4, TLR5, and NOD2
in GSD with IBD, and then further evaluated these in a case-control study with more
than 50 cases and healthy GSD controls. Several mutations in TLR4 and TLR5 were
found to be significantly associated with an increased risk of development of IBD.
Moreover, these results were replicated in 38 other non-GSD breeds for the TLR5
mutation.44 A follow-up study showed that peripheral blood cells of dogs carrying

Fig. 3. Immunofluorescence for CD11c on intestinal biopsies from (A) a healthy dog and (B)
a dog with IBD. CD11c expression in the intestinal mucosa is more abundant in healthy dogs
than in dogs with IBD (original magnification 100).

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 Small Intestinal Disorders in Dogs and Cats 531

the mutation are hyperresponsive to flagellin, which is the natural ligand for TLR5.45
This finding proves for the first time that a genetic mutation implicated in the pathogen-
esis of dogs with IBD has functional consequences at the protein level. Taken
together, these findings make it very likely that TLR5 mutations are causally associ-
ated with canine IBD. Genetic testing for these polymorphisms currently is available
only at the Royal Veterinary College. Such tests could become important for breeders
and practitioners in the future. However, it is likely that in a multifactorial disease such
as IBD in dogs, other genetic mutations and environmental factors also play a role in
the pathogenesis. With the advent of genome-wide association studies, it is possible
that more causative mutations will be identified.

SUMMARY

Many laboratory tests are available to aid the diagnostic workup of cats and dogs with
chronic small intestinal disorders. Some of these have been available for many years,
such as serum albumin and cobalamin concentrations, as well as canine pancreatic
lipase, and new data now show that these tests also may be prognostic indicators
in animals with chronic enteropathy. Other tests have only relatively recently become
available to practitioners, such as serum CRP, fecal a1-PI, WSAVA standardization of
histopathology readings, and PARR. The value of these tests needs to be evaluated in
every clinical situation. New tests that are not yet widely available, such as pANCA,
calprotectin, CD11c immunofluorescence, and genetic testing, may become very use-
ful tests in the future.

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