20TH ANNIVERSARY Vol. 21, No.

9 September 1999

CE Refereed Peer Review

Pathophysiology and
FOCAL POINT Management of Canine
★Colonic diseases in dogs are
relatively uncommon compared
with other gastrointestinal
Colonic Diseases
diseases; however, a firm
understanding of colonic Texas A&M University
physiology and diseases greatly Debra L. Zoran, DVM, PhD
aids in the management of large
intestinal disease.
ABSTRACT: Diet and infectious/parasitic agents are the most common causes of large bowel
diarrhea in dogs. A diagnosis of lymphocytic–plasmacytic colitis (the most common form of
KEY FACTS colonic inflammatory bowel disease) should be reserved for patients in which an etiologic
agent or dietary cause cannot be found. The cause of constipation should be established and
■ Signs of colonic disease range aggressively corrected or controlled to prevent progression to megacolon. This article dis-
cusses the basics of colonic physiology, reviews the diseases most commonly associated with
from diarrhea (small or large
colonic disease in dogs, and presents an approach to the management of these disorders.
bowel) to constipation, and these
distinctions are important in

C
ompared with disorders of the stomach or small intestine, colonic disease
formulating a diagnostic and
in dogs is uncommon. The clinical manifestation of colonic disease may
therapeutic approach.
be constipation or diarrhea, depending on the nature of the problem.
The unique physiology and function of the colon must be appreciated before
■ Management of colonic disease
appropriate treatment strategies can be implemented. This article discusses the
usually requires a combination
medical and dietary management of colonic diseases and relates the clinically rel-
of dietary and pharmacologic
evant aspects of colon physiology and function to treatment of those diseases.
interventions.
Although primarily directed at assisting practitioners in managing chronic co-
lonic disease, this information may also be useful in treating acute disease.
■ Lymphocytic–plasmacytic colitis
is a frequent diagnosis in dogs
BASIC COLONIC PHYSIOLOGY
with large bowel diarrhea, but the
The colon’s roles in conservation of water, sodium, and chloride ions and as
inflammatory cells can be from
a storage site of intestinal waste products until they are expelled as feces are
dietary, infectious, parasitic, or
well known. Its role in the final digestion and metabolism of ingesta is equally
immunologic causes.
important and often overlooked. There is ample and increasing evidence that
the microbial population of the colon plays a unique and important role in
■ Constipation must be
digestion and metabolism.1–3 Fermentation of dietary fiber by colonic mi-
aggressively treated in order to
crobes produces short-chain fatty acids (SCFAs), carbon dioxide, water,
prevent progression to chronic,
methane, and hydrogen gas; in turn, these byproducts affect the luminal
irreversible megacolon.
ecosystem and colonocytes.2 Enzymes in the colonic microflora convert pri-
mary bile acids into secondary bile acids, which are colonic epithelial cell irri-
tants and tumor promoters and may contribute to inflammatory bowel disease
(IBD) and neoplasia.4,5
There has been much interest recently in the use of fructooligosaccharides
(FOS) to enhance the colonic microflora and aid in the prevention and treat-
Compendium September 1999 20TH ANNIVERSARY
ment of colonic disease in humans and dogs.6,7 FOS are
complex carbohydrates that are not digested by the
small intestine enzymes; rather, they are fermented by
specific colonic microbes that use them as an energy
substrate. Because they are not used by pathogenic bac-
teria for energy, FOS “feed” the beneficial bacteria in
the colon while inhibiting the growth of other less de-
sirable species.8 Thus FOS are potentially beneficial not
only for their fermentability and production of SCFAs
but also because they selectively provide an energy sub-
strate for the normal bacterial flora.
The proximal colon (i.e., the ascending and trans-
verse segments) is the primary site of fermentation of
undigested carbohydrates and proteins by the bacterial
flora. Dietary fiber is the primary substrate for bacterial
fermentation, but not all dietary fibers are fermented
equally. Fibers are grouped based on their fermentabili-
ty: (1) highly fermentable fibers (e.g., FOS, citrus pec-
tin, carrageenan, vegetable gums), (2) moderately ferm-
entable fibers (e.g., beet pulp, oat fiber, rice bran), and
(3) poorly fermentable fibers (e.g., cellulose, peanut
hulls, lignin).9 The more fermentable the fiber is, the
more SCFAs are produced; the fermentation process
also reduces fecal bulk. 9 Conversely, the less ferm-
entable a fiber is, the more it retains its structural char-
acteristics and fecal bulk; however, a lower concentra-
tion of SCFAs is produced.
Production of SCFAs (e.g., acetate, propionate, bu-
tyrate) is important because they are used by colonic
epithelial cells as a source of metabolic energy and are a
substrate for cellular lipid synthesis. Butyrate is the pri-
mary source of metabolic fuel used by the colonic ep-
ithelium in rats, pigs, and humans10; in dogs, however,
butyrate and glucose appear to be equally important
substrates for metabolic energy.11 The presence of bu-
tyrate in the colonic lumen provides a readily available
source of energy for colonic epithelial cells, which have
a continuous need for metabolic fuel because of their
rapid turnover rate and constant growth and mainte-
nance requirements. The production of SCFAs also
serves several other important purposes: SCFAs are the
primary cations in the colonic lumen (which helps
maintain a more acidic pH)12 and are involved in sodi-
um and water fluxes in the colon.13 An acidic luminal
pH reduces the ionization of long-chain fatty acids and
bile acids (both are colonic irritants),4 increases the
concentration of ammonium ions (which are unable to
cross the cell membrane and thus are excreted in feces),14
and reduces the sporulation and overgrowth of path-
ogenic bacteria (e.g., Clostridium species).15
Although bacterial population and fermentation ac-
tivities are the greatest in the proximal colon, the distal
colon is the major site of fecal storage and is important
FOS ■ FIBER FERMENTABILITY ■ SCFAs ■ SEGMENTATION ■ PERISTALSIS
Small Animal/Exotics
in determining the final water content of fecal material.
Because of this storage function, distal colonocytes are
often exposed to bacterial or dietary toxins and other
luminal irritants (e.g., bile acids, ammonia) that can in-
jure the epithelial cells that line the gut.5,16 Increased
amounts of moderately or poorly fermented fiber in the
fecal stream result in greater fecal bulk and dilution po-
tential (i.e., ability to dilute luminal substances via in-
creased fecal mass and water). In addition, increased fe-
cal bulk stimulates colonic motility and reduces the
retention time of feces in the colonic lumen. Thus the
best fibers for improving distal colonic function and re-
ducing the exposure of colonocytes to luminal toxins
are those that are incompletely fermented by the mi-
croflora of the proximal colon.
The role of the colon in metabolism and storage of
ingesta is clearly important, but colonic motility is an
equally important component of normal gastrointesti-
nal (GI) tract function and one that is frequently al-
tered in disease states. The motor activity of the colon
is similar to that of the small intestine (i.e., segmenta-
tion and propulsive movements are present).17 Segmen-
tation is responsible for mixing the contents of the
colonic lumen by slowing passage of ingesta and is con-
trolled by the slow-wave activity of colonic smooth
muscle. Rhythmic segmentation within the colon is
controlled by local events (e.g., the primary stimulus in
the normal colon is distention by contents) via the in-
trinsic nervous system. The slow-wave activity generat-
ed in the colon is less than five cycles per minute—the
slowest activity cycle in the GI tract.17
Propulsive motor activity occurs in three patterns in
the colon: peristaltic activity, reverse peristalsis, and
mass peristalsis.17 Peristalsis, or propulsion, is the aborad
movement of ingesta through the colon by tonic con-
tractions of smooth muscle. These contractions are
stimulated by the presence of ingesta or distention of
the lumen (e.g., as occurs with poorly fermentable
fiber). Reverse peristalsis is unique to the proximal colon
and is characterized by contractions that move cephalad.
The motility pattern in the proximal colon is primarily
a combination of segmentation and reverse peristalsis,
which serves to thoroughly mix food and allows com-
plete absorption of necessary nutrients, SCFAs, and ions
before the remaining contents are slowly moved distally.
In addition to reverse peristalsis, peristalsis, and seg-
mentation, the colon has another unique propulsive mo-
tor activity called mass peristalsis17: Spike bursts in the
middle of the colon generate a migrating spike burst that
is responsible for a mass movement that propels the
colonic contents caudally. In the distal colon, the primary
motor pattern is segmentation and propulsion; the mass
peristaltic activity occurs during the act of defecation. De-
Small Animal/Exotics 20TH ANNIVERSARY
creased segmentation and/or propulsion leads to the de-
velopment of diarrhea, whereas increased segmentation
results in constipation. The addition of moderately or
poorly fermentable fibers to the diet normalizes motility
patterns in animals with large bowel disease by stimulat-
ing both segmentation and peristalsis18; however, consti-
pation can also occur if excess amounts of dietary fiber are
given or the animal is not adequately hydrated.
COLONIC DISEASES CAUSING DIARRHEA
Colonic diseases that cause diarrhea are associated with
signs of tenesmus, increased mucus in the stool, hema-
tochezia, increased frequency of defecation, and de-
creased stool volume and generally occur without vomit-
ing or weight loss. However, diarrhea with small bowel
characteristics may occur in dogs with inflammatory or
infectious diseases that affect both segments of the GI
tract. Colitis (e.g., colonic IBD) is the most common di-
agnosis in dogs with chronic large bowel diarrhea, but
dietary intolerance or indiscretion and bacterial, parasitic,
and neoplastic diseases are also important causes of
colonic disease that must be considered (see Causes of
Causes of Large Bowel Diarrhea in Dogs
Dietary Indiscretion, Intolerance,
or Hypersensitivity
■ Indiscretion: Adverse reaction to ingestion of
unusual foodstuffs such as garbage or table
scraps; abrupt change in diet; excess ingestion of
foodstuffs (gluttony); or ingestion of nonfoods
(pica) such as bones, hair, plants, or foreign objects
■ Intolerance: Abnormal response to an ingested
food or food additive that is not an immunologic
reaction; these include metabolic, pharmacologic,
or idiosyncratic reactions
■ Hypersensitivity: Adverse reaction to food that
has a proven immunologic basis
Infectious/Inflammatory Agents
■ Bacterial: Clostridium perfringens, Salmonella
species, Campylobacter species, Yersinia
enterocolitica, Escherichia coli, Clostridium
difficile, bacterial overgrowth in the small intestine
■ Parasitic: Trichuris vulpis (whipworm),
Ancylostoma caninum (hookworm), Giardia
lamblia (protozoan), Pentatrichomonas hominis
TENESMUS ■ HEMATOCHEZIA ■ CHRONIC COLONIC DISEASE ■ COLONIC GOBLET CELLS
Compendium September 1999
Large Bowel Diarrhea). This section reviews the more
common causes of large bowel diarrhea and focuses on
chronic (i.e., longer than 3 weeks’ duration) colonic dis-
eases. A suggested diagnostic approach to evaluate dogs
with colonic disease is presented in Figure 1.
Colitis
Although inflammatory diseases of the colon are
common causes of large bowel diarrhea in dogs, often a
cause is not identified and the diagnosis is based on
histopathologic description. Regardless of whether a
definitive diagnosis is obtained, the end result of in-
flammatory disease in the colon is a reduction in water
and electrolyte absorption and a change in motility that
causes increased frequency and urgency of defecation.
Colonic goblet cells are stimulated to increase mucus
production; in severe cases, mucosal ulceration occurs,
resulting in hematochezia.
The most common inflammatory response in canine
colitis is an increase in lymphocytes and plasma cells,
and the histologic diagnosis is lymphocytic–plasmacytic
colitis.19 However, the cellular infiltrate may consist of
(protozoan), Entamoeba histolytica (protozoan),
Balantidium coli (protozoan), Cryptosporidium
species (protozoan)
■ Fungal: Histoplasma capsulatum, Candida species
■ Miscellaneous: Heterobilharzia americana
(schistosomiasis), Prototheca species (algae)
Miscellaneous
■ Metabolic: Pancreatitis, ulceration secondary
to neurologic disease/corticosteroids, vascular
ectasia (congenital)
■ Neoplasia: Adenocarcinoma, leiomyosarcoma,
lymphosarcoma, mast cell tumors, adenoma,
leiomyoma, fibrosarcoma, extramedullary
plasmacytoma, and benign polyps
■ Mechanical: Ileocolic intussusception, cecal
inversion, perianal disease, short colon,
enterocysts
■ Idiopathic: Lymphocytic–plasmacytic colitis,
eosinophilic (entero)colitis, histiocytic ulcerative
colitis, granulomatous (regional) colitis,
suppurative or neutrophilic colitis
Compendium September 1999 20TH ANNIVERSARY Small Animal/Exotics

Diagnostic Approaches in Canine Colonic Disease

Large bowel diarrhea

(tenesmus, increased mucus, hematochezia, increased urgency)

Acute Chronic
(<3 wk duration) (>3 wk duration)

History, Fecal Therapeutic Same initial Imaging

examinations Colonoscopy,
signalment, trial: diet, approach as for studies: proctoscopy
(salt, zinc
physical sulfate, anthelmintics acute cases, but radiography (for direct
examination: direct smear, (broad-spectrum add minimum data (survey, visualization,
Important in cytology; anthelmintic base (complete contrast), aspiration/
focusing conduct treatment), blood count, ultrasonography,
multiple fecal culture,
diagnostics antibiotics routine biochemistry scintigraphy biopsy)
examinations
over 2–3 days) (amoxicillin, profile, urinalysis); (motility)
tylosin, other tests to
metronidazole) consider include
trypsin-like
immunoreactivity
assay, bile
acid assay,
corticotropin
stimulation, food
sensitivity
elimination trials

Figure 1—Algorithm for the diagnosis of acute and chronic large bowel diarrhea in dogs.

eosinophils, neutrophils, lymphocytes, plasma cells,
macrophages, or a combination thereof. The presence
of these inflammatory cells in the lamina propria of the
colon or small intestine has been termed inflammatory
bowel disease. The accumulation of inflammatory cells
in the colon can occur with many different diseases,
however, and a diagnosis of IBD should be reserved for
those patients in which no identifiable cause can be
found and in which there is a significant (moderate to
severe) accumulation of inflammatory cells in associa-
tion with epithelial structural changes.
Lymphocytic–Plasmacytic Colitis
The most common histologic diagnosis in dogs with
IBD is lymphocytic–plasmacytic colitis. Evidence con-
tinues to point toward an immunologic mechanism in
the pathogenesis of this disease, but the cause is not
known and likely relates to a combination of dietary,
infectious, immunologic, and genetic factors.19–22 Un-
like the classic causes of human IBD, ulcerative colitis,
or Crohn’s disease, lymphocytic–plasmacytic colitis in
dogs is rarely associated with weight loss or ulcerative
lesions and is usually responsive to therapy. Neverthe-
less, dogs frequently have hematochezia, increased mu-
cus in the feces, and an increased urgency to defecate.19
In most cases of canine lymphocytic–plasmacytic co-
litis, a combination of dietary and pharmacologic ther-
apy will relieve clinical signs. Dietary therapy can be
provided by feeding a diet that consists of a novel pro-
tein and carbohydrate, is highly digestible, or is high in
fiber (Table I). Each approach has merits, depending
on the clinical situation, but there is no biopsy result or
series of tests that will help determine which is likely to
be successful. Thus the rule of thumb is to feed one

INFLAMMATORY BOWEL DISEASE ■ DIETARY THERAPY

 TABLE I
Commercial Prescription Diets for the Management of Canine Colonic Diseasesa
Diet Category Trade Name Contents
® ®
Hypoallergenic Hill’s Prescription Diet Canine d/d (canned and dry) Canned: whitefish or lamb, rice; dry: egg, rice
Small Animal/Exotics

(novel protein and (Hill’s Pet Nutrition, Topeka, KS)

carbohydrate sources) Eukanuba Veterinary Diets® Response Formula® FP/Canine Catfish, herring meal, potato
(canned and dry) (The IAMS Company, Dayton, OH)
IVD™ Limited Ingredient Diets™ Canine (canned and dry) Rabbit, venison, lamb, whitefish or duck, potato
(Innovative Veterinary Diets, Newport, KY)
Waltham® Veterinary Diet Canine Selected Protein Canned: lamb, rice; dry: catfish, rice
(canned and dry) (Waltham, Vernon, CA)
CNM HA-Formula® Canine Diet (dry) Modified soy protein, corn starch
(Pro-Visions, Pet Specialty Enterprises, a division of Ralston
Purina Company, St. Louis, MO)
CNM LA-Formula® Canine Diet (dry) (Pro-Visions) Salmon meal, rice
Highly digestible Hill’s Prescription Diet® Canine i/d® (canned and dry) Soy fiber (soluble fiber)
(low fat, low residue) (Hill’s Pet Nutrition)
Eukanuba Veterinary Diets® Low-Residue Formula™/ Beet-pulp fiber (mixed fiber), FOS, fish oil
Canine (dry) (The IAMS Company)
IVD™ Select Care™ Canine Neutral Formula (dry) Duck, potato, oat bran, oat-hulls fiber, FOS
(Innovative Veterinary Diets)
IVD™ Select Care™ Canine Sensitive Formula Canned: chicken, egg, cottage cheese, oat bran, guar fiber (soluble),
(canned and dry) (Innovative Veterinary Diets) FOS; dry: lamb, rice, potato, pea fiber (mixed), FOS
20TH ANNIVERSARY

Waltham® Veterinary Diet Canine Low Fat Canned: fish, meat, rice, cellulose powder, carrageenan, carob fiber
(canned and dry) (Waltham) (mixed fiber); dry: ground wheat fiber (mixed fiber), soy protein, rice
CNM EN-Formula® Canine Diet (canned and dry) Canned: beef, rice, egg product, no fiber, MCTs, fish oil; dry: rice,
(Pro-Visions) corn, no fiber, MCTs, fish oil
High dietary fiber Hill’s Prescription Diet® Canine w/d® (canned and dry Canned: cellulose fiber (insoluble fiber); dry: peanut hulls
(low fat, high fiber) (Hill’s Pet Nutrition) (insoluble fiber)
Hill’s Prescription Diet® Canine r/d® (canned and dry) Canned: cellulose (insoluble fiber); dry: peanut hulls
(Hill’s Pet Nutrition) (insoluble fiber)
IVD™ Select Care™ Canine Hifactor Formula Canned: cellulose, guar fiber (mixed fiber), FOS, fish oil;
(canned and dry) (Innovative Veterinary Diets) dry: poultry byproducts, corn, rice, peanut hulls, rice hulls
(insoluble fiber), FOS, fish oil
Waltham® Veterinary Diet Canine High Fiber (dry) Wheat bran, cellulose (mixed fiber)
(Waltham)
CNM DCO-Formula™ Canine Diet (dry) (Pro-Visions) Beet pulp, pea fiber (mixed), fish oil
CNM OM-Formula® Canine Diet (canned and dry) Canned: pea fiber, beet pulp (mixed); dry: pea fiber (mixed),
(Pro-Visions) soybean hulls (insoluble)
a
This list is not intended to be exhaustive but rather is representative of the wide variety of commercial products available from veterinarians for treatment of gastrointestinal disease.
FOS = fructooligosaccharides; MCTs = medium-chain triglycerides.
Compendium September 1999
Compendium September 1999 20TH ANNIVERSARY
diet for 3 to 6 weeks; if no beneficial response is seen,
another diet should be tried. A trial using a hypoaller-
genic diet (e.g., novel protein and carbohydrate source;
Table I) is important because of the possible association
of IBD with dietary intolerance or sensitivity.23 Alterna-
tively, feeding a high-fiber diet to dogs with colitis is
also a good strategy because of the beneficial increases
in luminal SCFA concentrations and fecal bulk.
If feeding a high-fiber or novel-protein diet is not ef-
fective, a low-residue diet can be tried (Table I). Low-
residue diets that contain FOS may prove to be espe-
cially helpful in dogs with colitis due to overgrowth of
bacterial pathogens or reduced numbers of normal flo-
ra; however, clinical studies reporting the effectiveness
of FOS in canine colitis are lacking. Because long-term
dietary management may be required in dogs with
IBD, using a commercial diet (rather than a homemade
diet or one supplemented with fiber) is often the best
approach for preventing nutritional deficiencies or im-
balances.
The pharmacologic treatment of choice for lympho-
cytic–plasmacytic colitis continues to be sulfasalazine,
which is sulfapyridine linked to 5-aminosalicylic acid
(5-ASA; the active drug). Its mechanism of action is be-
lieved to be via its antileukotriene activity24 and free
radical scavenging ability. Other actions may include
inhibition of lymphocyte responsiveness and natural
killer cell activity and reduced production of cytokines
by lymphocytes.24 The azo bond serves as a vehicle to
deliver the active molecule to the colon, where bacterial
enzymes (azoreductases) cleave the bond to free the 5-
ASA.24
Newer aminosalicylic preparations (mesalamine) are
available that allow delivery of 5-ASA without the sulfa
moiety, which is believed to be responsible for the nu-
merous adverse effects (keratoconjunctivitis, vomiting)
associated with sulfasalazine use. These newer products
include oral delayed-release preparations of mesal-
amine, which prevent its absorption in the upper GI
tract, and products that have an azo bond (e.g., sulfa-
salazine) but in which the sulfa component has been re-
placed with another amine (balsalazide, a prodrug of
mesalamine; not available in the United States) or a
second 5-ASA (olsalazine).24 Sulfasalazine and olsalazine
are the most common products used in dogs and have
established dosages (Table II). Because few of the other
mesalamine-containing drugs have been thoroughly
evaluated in dogs, dosages are empiric.
When using 5-ASA in the therapy of colonic IBD,
the key is to administer high doses until control is
achieved and then maintain that dose for 3 to 4 weeks
beyond clinical improvement. For patients that are not
responsive to diet and appropriate therapy with drugs
LOW-RESIDUE DIET ■ SULFASALAZINE ■ 5-ASA ■ MESALAMINE
Small Animal/Exotics
containing 5-ASA, combination therapy with pred-
nisolone, metronidazole, or such immunosuppressive
agents as azathioprine may be tried (Table II). Most
cases of lymphocytic–plasmacytic colitis are responsive
to routine dietary and treatment approaches; for dogs
that do not respond to therapy, clinicians should ques-
tion whether the correct diagnosis was made, the ani-
mal is receiving the medication and diet as directed,
and the dosage and frequency of drug administration
are adequate.
Eosinophilic Colitis
Eosinophilic colitis is characterized by accumulations
of eosinophils in the lamina propria and may also be as-
sociated with persistent peripheral eosinophilia.25 This
disorder is a chronic, idiopathic inflammatory disease
that affects the stomach, small intestine, and/or colon
of dogs. Food allergy has been incriminated in some
human patients26 but has not been proven in dogs. Spo-
radic reports have associated the disease with parasites27
and infectious agents,28 but these findings have not
been corroborated. Nevertheless, although the disease is
uncommon compared with lymphocytic–plasmacytic
colitis, it tends to be clinically more aggressive; hema-
tochezia and dyschezia are commonly observed.
In addition to dietary therapy, treatment of eosin-
ophilic colitis often requires immunosuppressive doses
of steroids, alone or in combination with 5-ASA com-
pounds or metronidazole, to achieve clinical remission.25
Efforts to reduce the steroid side effects in humans in-
clude use of steroid-containing rectal suppositories or
enemas, newer glucocorticosteroid preparations that
cause fewer systemic side effects (e.g., budesonide), or
such drugs as methotrexate to manage the disease.29,30
Histiocytic Ulcerative Colitis
Histiocytic ulcerative colitis, a rare cause of large
bowel diarrhea, has been reported only in boxers31,32
and a French bulldog.33 The occurrence of the disease
also seems to be somewhat regional, suggesting a possi-
ble genetic influence. This ulcerative form of colitis is
often associated with both watery mucoid diarrhea and
marked hematochezia, and patients with severe disease
may exhibit weight loss. The basis for a diagnosis of
histiocytic colitis is the finding of periodic acid-
Schiff–positive histiocytes in the lamina propria in con-
junction with other inflammatory cells.32 The prognosis
for this disease is very guarded because the response to
therapy is often poor, and recurrence is common even
in dogs that do respond to aggressive drug therapy.
Granulomatous Colitis
Granulomatous colitis is another rare form of colitis
Small Animal/Exotics 20TH ANNIVERSARY Compendium September 1999

TABLE II
Drugs for Treatment of Colonic Disease
Drug Trade Name Dosage a Indication/Action
Amoxicillin Many 10–20 PO or SC every 12 hr Salmonella, Clostridium
Ampicillin Many 10–40 PO or SC every 6–8 hr Salmonella, Clostridium
Azathioprine Imuran® 1–2 PO every 24–48 hr IBD, colitis
(Glaxco Wellcome,
Research Triangle
Park, NC)b
Barium sulfate Many 10–30 ml/kg PO once Contrast studies
Cefadroxil Cefa-Tabs® 10–30 PO every 12 hr Yersinia
(Fort Dodge,
Ft. Dodge, IA)
Cephalexin Many 10–30 PO every 8–12 hr Yersinia
Chlorambucil Leukeran® 0.2 PO every 24–48 hr IBD
(Burroughs Wellcome,
Research Triangle
Park, NC)
Chloramphenicol Many 40–50 PO every 6–8 hr Campylobacter
Chlordiazepoxide/clidinium Librax® 0.05–0.125 mg PO IBS
(Roche Products, every 8–12 hr
Manati, PR)
Clindamycin HCl Antirobe® 5–11 PO every 12 hr Anaerobes (Clostridium)
(Pharmacia & Upjohn,
Kalamazoo, MI)
Cisapride Propulsid® 0.1 PO every 8–12 hr Prokinetic
(Janssen Pharmaceutica,
Titusville, NJ)
Dicyclomine Many 0.15 PO every 8–12 hr IBS
Diethylcarbamazine/ Filaribits Plus® 5.0 PO every 24 hr Heartworm/whipworm
oxibendazole (Pfizer Animal Health, prevention
Exton, PA)
Diphenoxylate Many 0.1–0.2 PO every 8–12 hr Motility modifier
Docusate sodium Many 50–200 mg PO every 8–24 hr Stool softener
Doxycycline Many 2.5–5 PO every 12 hr Campylobacter, Yersinia
Enrofloxacin Baytril® 2.5–5 PO or SC every 12–24 hr Salmonella, Escherichia
(Bayer Corporation, coli
Shawnee, KS)
Erythromycin Many 10–20 PO every 8–12 hr Campylobacter
Febantel/praziquantel/ Drontal® Plus 1 small tablet/2–4 kg BW Hookworms,
pyrantel pamoate Tablets (Bayer (dogs weighing up to 25 lb) roundworms,
Corporation) or 1 large tablet/12–15 kg BW whipworms
(dogs weighing over 25 lb) PO
once
Fenbendazole Many 25–50 PO every 24 hr for 5 days Hookworms, whipworms,
Giardia
Gastrointestinal lavage Many 10–15 PO two doses every 2 hr Colonoscopy preparation
solution
Hyoscyamine Many 0.0005–0.0015 PO every 8 hr IBS
Lactulose Many 0.25–0.5 PO every 6–8 hr Stool softener
Loperamide Many 0.1–0.2 PO every 8–12 hr Motility modifier
Mebendazole Many 22 PO every 24 hr for 3–5 days Whipworms, hookworms
Mesalamine Many 10–22 PO every 8 hr IBD
Metoclopramide Many 0.2–0.5 PO or SC every 6–8 hr Prokinetic, antiemetic
Metronidazole Many 10–50 PO every 8–24 hr IBD, Clostridium,
Trichomonas, Giardia
Compendium September 1999 20TH ANNIVERSARY Small Animal/Exotics

TABLE II (continued)
Drug Trade Name Dosage a Indication/Action
Milbemycin oxime Interceptor ®
0.5 PO every 30 days Heartworm preventive,
(Novartis Animal whipworms, hookworms
Health, Greensboro, NC)
Olsalazine Dipentium® 10–22 PO every 8 hr IBD
(Pharmacia & Upjohn)
Orbifloxacin Orbax® 2.5–7.5 PO every 24 hr Salmonella, E. coli
(Schering-Plough
Animal Health,
Kenilworth, NJ)
Prednisolone Many 1–3 PO or SC every 12–24 hr IBD
Propantheline Many 0.25–0.5 PO every 8 hr IBS
Psyllium hydrophobic Many 1–3 tbsp/25 kg PO Fiber-responsive diseases
mucilloid every 8–24 hr
Sulfasalazine Azulfidine® 20–30 PO every 8 hr IBD
(Pharmacia & Upjohn)
Trimethoprim/ Many 15 PO every 12 hr Yersinia, Salmonella
sulfadimethoxasole
(or sulfadiazine)
Tetracycline Many 15–20 PO every 6–8 hr Campylobacter, Yersinia
Tylosin Many 7–15 PO every 8 hr IBD, Clostridium
a Dosages
are in mg/kg unless otherwise indicated.
bAlso
available generically.
BW = body weight; IBD = inflammatory bowel disease; IBS = irritable bowel syndrome; PO = orally; SC = subcutaneously.

reported in dogs. The presence of macrophages and
other inflammatory cells within the lamina propria is
similar to histiocytic ulcerative colitis, but these
macrophages are not periodic acid–Schiff positive.34
The cause is usually not identified in this type of coli-
tis, but it is very important to rule out histoplasmosis,
phycomycosis, and other infectious diseases before
starting immunosuppressive drug therapy. Like histio-
cytic colitis in boxers, this form of colitis can be unre-
sponsive to therapy and relapses are common. In one
reported case, surgical resection of the colon was used
to control refractory disease.34
Colitis Secondary to Dietary Indiscretion,
Intolerance, or Sensitivity
Dietary indiscretion, intolerance, or sensitivity can
also cause large bowel diarrhea in dogs. Dietary indis-
cretion is defined as the ingestion of excess quantities of
a normal diet, feedstuffs not considered to be part of
the animal’s normal diet (e.g., table food, garbage,
treats, new diet), or nonfood substances (e.g., foreign
matter, rocks, bones) that cause GI tract disturbances
and result in vomiting or diarrhea. Dietary intolerance is
a nonimmunologic reaction to a substance(s) in food.23
Diarrhea due to dietary indiscretion or intolerance
can be induced by several effects on the colonic luminal
environment: (1) a change in the amount of osmotical-
ly active particles present in the lumen, (2) a change in
the bacterial flora resulting in an increase in fermenta-
tion products or change in flora (overgrowth of
Clostridium species), or (3) the presence of physical
(abrasive) or chemical materials that induce an inflam-
matory response and mucosal injury. Diagnosis of this
syndrome is primarily based on the history, presenting
signs, lack of other identifiable causes (Figure 1), and
response to dietary change or removal of the offending
substance from the diet.
One treatment approach for dogs with diarrhea due
to dietary indiscretion is to give nothing by mouth for
24 hours and then feed a low-fat, highly digestible diet
(Table I). Alternatively, a low-fat, high-fiber diet may
help restore normal colonic motility. In patients with
significant pain or distress, motility-modifying drugs
(e.g., loperamide) may be used to promote fluid and
electrolyte resorption by restoring the normal segmen-
tation contractions of the bowel. If clinical signs persist
for more than 3 to 5 days or are associated with other
GI tract signs, the dog should be reevaluated and other
diagnoses considered. In contrast to dogs with dietary
indiscretion, dogs with dietary intolerance must be
switched to a diet that does not contain the offending
substance(s), typically a hypoallergenic diet (Table I); in

RULE-OUTS FOR GRANULOMATOUS COLITIS ■ MOTILITY-MODIFYING DRUGS

Small Animal/Exotics 20TH ANNIVERSARY
some cases, feeding a highly digestible (premium
brand) dog food rather than a grocery- or feed-store
brand may be effective.
Dietary sensitivity is most commonly associated with
vomiting, small bowel diarrhea, and dermatologic
signs; large bowel diarrhea may be rarely observed.35
When dietary sensitivity is suspected, a dietary trial
must be conducted using a controlled diet that is based
on both highly digestible and novel protein and carbo-
hydrate sources.35 In some cases, commercial hypoaller-
genic diets will be sufficiently novel to both prove the
diagnosis and treat the disease (Table I). However,
homemade or elemental diets may be required to con-
trol the hypersensitivity.35 Because the risk of inducing
nutritional deficiencies is much greater with homemade
diet preparations, it very important to consult a clinical
nutritionist (if possible) or, for long-term management,
choose the most effective commercial diet.
Infectious, Inflammatory,
and Parasitic Disorders
Whipworm (Trichuris vulpis) is the most common par-
asitic cause of large bowel diarrhea in dogs; however,
whereas whipworm colitis is common in some areas, it
does not occur in all regions of the world. Problems asso-
ciated with whipworm colitis are related to several factors:
(1) diagnosis is difficult because oocysts are shed intermit-
tently, (2) infective stages persist in the environment for
months to years, and (3) acquired immunity is apparently
lacking.36
The treatment of choice for whipworm infection is
the benzimidazole anthelmintics, of which fenbenda-
zole is the most well known. Other products, including
febantel and milbemycin oxime (Table II), are also
quite effective. The use of milbemycin oxime in month-
ly heartworm preventives has decreased the prevalence
of many intestinal parasites, including whipworm.37
Dogs with whipworm colitis should be retreated with
fenbendazole (or febantel) every 6 to 12 weeks for sev-
eral months to destroy the prepatent infection and pre-
vent reinfection.36 However, monthly treatment with
milbemycin oxime plus frequent, aggressive cleaning of
kennels, runs, and yards is necessary to control chronic
or recurrent clinical disease.
Giardia species are protozoan parasites of the small
intestine that typically cause small bowel diarrhea, but
development of large bowel diarrhea (hematochezia or
increased fecal mucus) is not unusual. Detection of Gi-
ardia trophozoites or oocysts in the stool is often diffi-
cult, and treatment based on a presumptive diagnosis
may be necessary. Trophozoites may be identified on
examination of numerous direct fecal smears. The best
approach, however, is to identify oocysts using zinc sul-
WHIPWORMS ■ BENZIMIDAZOLE ANTHELMINTICS ■ GIARDIA ■ CLOSTRIDIUM
Compendium September 1999
fate flotation techniques. Multiple fecal samples should
be examined before pronouncing the fecal sample nega-
tive.
Other diagnostic methods include aspiration of lumi-
nal contents via endoscopy or a fecal ELISA marketed
for human use. 38 In a recent report, however, the
ELISA was found to have a 14% false-negative rate in
zinc sulfate–positive dogs39 and thus is not recommend-
ed. The long-standing recommended treatment for Gi-
ardia has been 10 to 14 days of metronidazole (Table
II), but many Giardia species are resistant to this drug.
Fenbendazole or albendazole administered for 5 consec-
utive days40 (Table II) may be successful in resistant cas-
es. Client education is essential because of the organ-
ism’s zoonotic potential. Finally, a Giardia vaccine
(GiardiaVax™; Fort Dodge, Ft. Dodge, IA) has recent-
ly been developed and may be an important preventive
in regions with severe Giardia problems; side effects,
duration, and effectiveness in the clinical setting have
not been independently reported.
Clostridium perfringens is a common cause of acute or
chronic diarrhea in dogs. This bacterium is a normal
inhabitant of the GI tract but is typically found in its
vegetative form, which does not produce enterotoxin.15
Enterotoxin, which can be produced when the organ-
ism undergoes sporulation, is responsible for the resul-
tant diarrhea.15 Sporulation tends to occur in the distal
small intestine and proximal colon and is enhanced by
an alkaline intestinal luminal environment. Although
the normal proximal colon is relatively acidic, dietary
changes, antibiotics, microorganisms, or stress may al-
ter this environment, making conditions favorable for
sporulation and subsequent enterotoxin production.15
Dogs with clostridial enterotoxin–induced diarrhea
have signs of either small or large bowel diarrhea. The
definitive diagnosis of clostridial enterocolitis requires
identification of clostridial spores and the presence of
enterotoxin in the feces using either a fecal ELISA or
reverse passive latex agglutination (RPLA) test. Howev-
er, a recent study has shown that the RPLA test does
not correlate well with the number of fecal endospores
and thus may not be a reliable test.40a Fecal cytology
alone is a quick and simple screening test for the dis-
ease, and identification of a large number of spores
(more than five per high-power field) in the feces of
dogs with typical clinical signs correlates well with a
positive enterotoxin assay. The safety-pin shape of the
spores makes them easily identifiable on smears stained
with Diff-Quik® (Figure 2).
In some cases, spores found on fecal cytology may
represent a nonenterotoxigenic strain of Clostridium
species. Alternatively, clostridia may be secondary to
other intestinal diseases, such as parvoviral enteritis,
Small Animal/Exotics 20TH ANNIVERSARY Compendium September 1999

hemorrhagic gastroenteritis, Therefore, other causes of

giardiasis, or IBD, 15,41 and large bowel diarrhea should
contribute to the severity of be thoroughly investigated
the disease. If there is a before a diagnosis of IBS is
question as to whether the made.
presence of fecal spores is Because dietary fiber may
clinically significant, clini- normalize myoelectric activ-
cians should either perform ity, motility, and GI transit
the RPLA assay or simply times, dietary fiber supple-
treat for the disease. mentation (especially with
Antibiotics that are effec- poorly fermentable fiber) is
tive against anaerobic bacte- a commonly recommended
ria (e.g., amoxicillin, ampi- treatment in humans. 42 In
cillin, tylosin, clindamycin, dogs in which diarrhea is
metronidazole; [Table II]) Figure 2—Photomicrograph (original magnification ×100) of the primary sign, motility
®
are also effective in reducing a fecal sample stained with Diff-Quik . There is a mixed modifiers (e.g., diphenoxy-
clostridial overgrowth and en- population of bacteria that includes numerous (more than late or loperamide) may re-
five per high-power field) Clostridium species spores. The
terotoxin production. Clini- spores have a characteristic safety-pin shape and are larger sult in significant improve-
cal signs in most dogs with than the other bacterial species present. ment (Table II).42 Dogs that
acute disease will resolve in have abdominal pain or in-
3 to 5 days. For dogs with creased flatulence may re-
chronic or recurrent clostridial enterocolitis, long-term spond to tranquilizer–antispasmotic drugs, such as
(4 to 6 weeks) antibiotic therapy is required.15 Because chlordiazepoxide (a benzodiazepine sedative) and cli-
fermentation of dietary fiber reduces the luminal pH dinium bromide (an anticholinergic; Table II).42 Other
and decreases the sporulation of clostridia, feeding a drugs that may be useful in controlling IBS include
diet that contains moderate or highly fermentable fiber propantheline or dicyclomine (Table II). Any of these
will also be beneficial (Table I). Adding highly fer- drugs should be used on a short-term basis and general-
mentable fibers (psyllium, oat fiber, canned pumpkin) ly only when the disorder flares up. Finally, because
to the diet (1 to 4 tbsp/25 kg body weight) is also bene- clients can easily become frustrated with their pet’s con-
ficial but may decrease the diet’s palatability and should dition, it is essential that good client communication is
not be used long term. established.

Irritable Bowel Syndrome Colonic Neoplasia

Irritable bowel syndrome (IBS) is a poorly defined
disorder in dogs that causes diarrhea, but a histologic
lesion or organism cannot be identified. In humans, the
disorder has also been termed spastic colon, nervous
colon, and spastic colitis.42 It is often a recurrent cause of
large bowel diarrhea in young, hyperactive, or stressed
dogs and therefore resembles IBS in humans. Animals
with IBS have no other outward signs of disease, and
the colon is histologically normal; thus IBS is classified
as a functional disorder. The disease is presumed to
have an neurologic component, with altered colonic
motility or sensation, but this has not been proven in
dogs. Humans with IBS often have documented motili-
ty disorders, but the relationship of these disorders to
the disease itself is still not clear.
Clinically, IBS is characterized by a chronic, intermit-
tent pattern of signs ranging from increased flatulence,
nausea, and abdominal pain to dyschezia, mucoid
stools, hematochezia (less common), and tenesmus.
This uncommon disorder is a diagnosis of exclusion.
Tumors of the GI tract represent only 1% of all ca-
nine malignancies; however, the colon and rectum are
the most common sites of GI neoplasia in dogs.43 Ade-
nocarcinoma is the most common intestinal tumor in
dogs,43 and leiomyosarcoma is the most common sarco-
ma.44 Adenomatous polyps of the rectum are the most
common benign growths.45 Other tumors affecting the
colon and rectum include lymphosarcoma, fibrosarco-
ma, leiomyoma, extramedullary plasmacytoma, mast
cell tumor, and undifferentiated sarcomas. Adenocarci-
nomas of the colon typically occur in older dogs (mean
age, 9 years) and may be annular or intraluminal.46,47
Clinical signs include changes in fecal size (due to lu-
minal constriction), large bowel diarrhea, and constipa-
tion. However, one relatively consistent clinical sign is
weight loss, which is unusual with other large bowel
diseases.47 Thus neoplastic disease must be a major con-
sideration in any older dog with signs of weight loss,
anorexia, or lethargy.
The most common treatment for large intestinal non-

MOTILITY MODIFIERS ■ TRANQUILIZER–ANTISPASMODIC DRUGS ■ ADENOCARCINOMA

Small Animal/Exotics 20TH ANNIVERSARY
Causes of Constipation, Obstipation, or Megacolon in Dogs50
Environmental
■ Hospitalization
■ Inactivity
■ Change of habitat
Extraluminal Colonic Obstruction
■ Prostatic disease (e.g., hypertrophy, neoplasia,
abscess, cysts)
■ Fractures involving the pelvic canal
■ Neoplasia (primary or metastatic)
■ Abdominal masses (e.g., abscesses, cysts that
compress the colon)
■ Obstruction of perineum with hair, feces, or masses,
resulting in decreased ability to evacuate the colon
Intraluminal Colonic Obstruction
■ Foreign material (e.g., hair, bones, plant material,
plastic, toys)
■ Neoplasia (annular constriction, pedunculated
growths, polyps)
■ Granuloma
■ Rectal or colonic diverticulum
■ Perineal hernia
Neuromuscular
■ Lumbosacral spinal cord disease or injury
■ Pelvic nerve injury
■ Dysautonomia
lymphoid neoplasia is surgical resection. Postoperative
adjuvant chemotherapy appears to be of little benefit in
dogs with adenocarcinoma.48 Radiation therapy has
shown encouraging results in the treatment of rectal
tumors.49 In contrast to malignant tumors, colorectal
polyps have an excellent prognosis if they are completely
excised. Recurrence is possible, especially with large le-
sions that are difficult to excise completely, but not com-
mon. Polyps, especially those that are most distal and ses-
sile, can also be treated by electrosurgery or cryosurgery.47
COLONIC DISEASES CAUSING CONSTIPATION
Infrequent or difficult evacuation of feces is termed
constipation. Obstipation refers to intractable constipa-
tion that is refractory to control or cure and implies a
permanent loss of function. The numerous causes of
constipation in dogs often relate to the indiscriminate
eating habits of the species. An attempt should be made
POLYPS ■ DILATION ■ HYPERTROPHY ■ COLONIC IMPACTION
Compendium September 1999
Metabolic
■ Dehydration
■ Hypercalcemia (e.g., neoplasia,
hyperparathyroidism, renal secondary
hyperparathyroidism, hypoadrenocorticism,
renal failure, toxicity [vitamins A and D])
■ Hypokalemia (e.g., vomiting/diarrhea, renal
failure, hyperadrenocorticism, alkalemia,
drug-induced)
■ Hypothyroidism
Pain-Induced
■ Anorectal diseases (e.g., anal sac impaction/
abscess, stricture, perianal fistulas, proctitis)
■ Orthopedic diseases (e.g., pelvic, spinal, or rear
limb fractures)
Iatrogenic
■ Opioid analgesics
■ Antacids
■ Anticholinergics
■ Anticonvulsants
■ Barium sulfate
■ Carafate
■ Diuretics
to determine the underlying cause in every case (see
Causes of Constipation, Obstipation, or Megacolon in
Dogs50). Either constipation or obstipation may culmi-
nate in the syndrome of megacolon, which occurs via
the process of dilation or hypertrophy. Dilation is the
endstage of idiopathic megacolon (common in cats,
rare in dogs) or neurologic dysfunction, whereas hyper-
trophy develops as a consequence of some obstructive
mechanism (intraluminal or extraluminal).51 The pres-
ence of hardened feces in the colon, termed colonic im-
paction, is a consequence of constipation, obstipation,
or megacolon but does not necessarily imply perma-
nent loss of function. Diagnosis of constipation is rela-
tively straightforward; however, functional evaluation
of a dilated colon to assess the reversibility of the condi-
tion requires anorectal manometry, pelvic floor elec-
tromyography, motility assessments, and intestinal
transit time tests, none of which are routinely available.
 Compendium September 1999 20TH ANNIVERSARY Small Animal/Exotics

Constipation, Obstipation, and Megacolon
Constipation is a common but easily managed prob-
lem in most dogs. For the more difficult problems of
chronic constipation or obstipation, however, the incit-
ing cause must be identified and corrected before treat-
ment will be successful (see Causes of Constipation,
Obstipation, or Megacolon in Dogs). The initial thera-
py of constipation is aimed at removing feces from the
colon and rectum. In de-
hydrated dogs, fluid thera-
MPENDIU py is often necessary to
M’
The end result is a bulkier, softer stool that is easier to
pass. Alternatively, fiber sources can be added to existing
diets in the form of bulk-forming laxatives, such as psylli-
um, but this approach is not recommended for long-term
management of constipation. The emollient and lubri-
cant laxatives, such as DSS and petroleum jelly, result in a
softer stool either by increasing fecal water or simply lu-
bricating the fecal mass. These laxatives are good for
short-term management of mild constipation and in soft-
ening a fecal mass that contains hair, bones, or the like
but are not effective for therapy of chronic constipation.

20th

CO

help soften the stool. Intra- Osmotic laxatives, such as lactulose or polyethylene
S

1 9 7
9 - 1
9 9 9
venous fluid therapy is pre-
ANNIVERSARY
ferred to oral rehydration
in most severe cases. Multi-
A LookBack ple enemas will be required
to evacuate the colon in se-
There have been a number of verely constipated or obsti-
exciting changes in our pated dogs. The type of
understanding of colonic diseases enema solution varies, but
warm water should be used
of dogs and cats. The role of
initially. Dioctyl sodium
different diets (e.g., highly
sulfosuccinate (DSS) is an
digestible, high-fiber, novel emollient that can be add-
protein) and dietary components ed to warm water solutions
(e.g., fructooligosaccharides, to help soften the stool;
fiber, protein sources) in the however, DSS irritates the
management of colonic diseases colonic epithelium.52 Ene-
is an especially important area ma solutions (0.5 to 1 L,
of research interest. The depending on the dog’s
size) should be adminis-
increased availability and
tered by gravity flow.52 So-
awareness of endoscopy as a
lutions containing soaps or
diagnostic tool has improved the phosphate salts should be
ability to diagnose colonic avoided because of their ir-
disease. Finally, we have better ritant or toxic effects. In
drugs to manage motility dogs with severe impac-
disorders (e.g., cisapride) and tion, the fecal mass may be
are beginning to understand broken down with gentle
gastrointestinal motility and its digital manipulation or
forceps.
role in disease. Nevertheless, we
Management or preven-
still do not understand tion of constipation is di-
inflammatory bowel disease or
rected at diet changes or
the importance of diet and its the addition of laxatives.
effect on colonic microflora in Increasing fecal bulk with
health and disease. dietary fiber that is moder-
ately or poorly ferment-
able stimulates the defeca-
tion reflex and shortens
transit time while increas-
ing SCFAs and microbes,
thus softening the stool.
glycol–electrolyte solutions, increase intraluminal water
content via their osmotic properties and are fermented
by the colonic microflora (like fermentable fiber),
which also increases fecal water content. Stimulant lax-
atives, such as bisacodyl or phenolphthalein, increase
the propulsive contractions of the colon and decrease
colonic water absorption. They are very effective laxa-
tives for short-term use but should not be used in dogs
with severe obstipation and are not well tolerated for
long-term (daily) use in dogs. Prokinetic therapy with
cisapride will increase colonic smooth muscle contrac-
tions and is especially useful in dogs with postoperative
ileus or constipation nonresponsive to fiber or laxative
supplementation and in some patients with loss of func-
tion.52 In severe cases of obstipation or megacolon that
are unresponsive to fiber and drug therapy, a subtotal
colectomy may be considered.53 However, there are
many complications associated with this procedure in
dogs, and it should only be used as a last resort.
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About the Author
Dr. Zoran is affiliated with the Department of Small Animal
Medicine and Surgery, College of Veterinary Medicine,
Texas A&M University, College Station, Texas. She is a
Diplomate of the American College of Veterinary Internal
Medicine.