Peer Reviewed Symptomatic Management of Primary Acute Gastroenteritis

Symptomatic Management of
Primary Acute Gastroenteritis
Yuri Lawrence, DVM, MA, MS, Diplomate ACVIM (Small Animal Internal Medicine), and
Jonathan Lidbury, BVMS, MRCVS, Diplomate ACVIM (Small Animal Internal Medicine) &
ECVIM (Companion Animal)
Texas A&M University

Acute gastroenteritis is a term used to describe a

Table 1.
syndrome characterized by the sudden onset of
Selected Causes of Secondary Acute
vomiting and/or diarrhea caused by gastrointestinal
Gastroenteritis
mucosal inflammation.
Algal • Prototheca species
This diagnosis is seldom confirmed by
Bacterial • Campylobacter species histopathologic evaluation; instead, it is based on
• Clostridia species a consistent clinical presentation and exclusion of
• Escherichia coli
• Neorickettsia helminthoeca other potential causes for the patient’s clinical signs.
• Salmonella species Mucosal inflammation is assumed, but not proven
Drugs • Antibiotics to be present. Therefore, acute gastroenteropathy is
• Cyclosporine perhaps a more appropriate name.
• Glucocorticoids
• Mycophenolate
• Nonsteroidal anti-inflammatory drugs DIAGNOSTIC EVALUATION
Acute gastroenteritis is among many potential
Parasitic • Ancylostoma caninum
• Ollulanus tricuspis causes of acute vomiting and diarrhea (Table 1).
• Physaloptera species However, in many cases, the cause of primary acute
• Strongyloides species gastroenteritis is not determined. Rapid resolution
• Toxoascaris leonina of clinical signs often means that extensive diagnostic
• Toxocara canis
evaluation is unnecessary.
Protozoal • Cryptosporidium parvum
• Giardia species
• Isospora canis Physical Examination
Systemic • Bacterial cholecystitis No specific physical examination findings are
disease • Gallbladder mucocele pathognomonic for acute gastroenteritis, and some
• Gastric dilatation and volvulus dogs do not have any significant abnormalities.
• Hepatic disease
Findings consistent with acute gastroenteritis include
• Hypoadrenocorticism
• Pancreatitis lethargy, pytalism, and abdominal discomfort.
• Pyometra It is particularly important to assess the patient’s
• Renal disease hydration status and palpate the abdomen carefully,
• Sepsis
checking for physical examination findings that
• Septic peritonitis
• Splenic torsion would warrant further diagnostic evaluation (ie,
• Chocolate abnormalities that suggest the problem is more
Toxins
• Lead significant than straightforward acute gastroenteritis)
• Mushrooms (Table 2). Findings that indicate dehydration
• Organophosphates include dry oral mucous membranes, prolonged
• Xylitol
• Zinc capillary refill time, and prolonged skin tent.
Tachycardia, weak pulses, and cool extremities are
Viral • Canine coronavirus
• Canine parvovirus consistent with hypovolemia.
• Feline immunodeficiency virus
• Feline leukemia virus Laboratory Analysis
• Feline parvovirus (panleucopenia virus) Patients with a normal physical examination and

46 Today’s Veterinary Practice | November/December 2015 | tvpjournal.com

 SyMPTOMATIC MANAGEMENT OF PRIMARy ACUTE GASTROENTERITIS Peer Reviewed

mild clinical signs may not require laboratory testing

on initial presentation. However, laboratory testing
may be indicated to rule out extra-gastrointestinal
causes of acute gastrointestinal signs, such as acute
kidney injury, acute hepatitis, and pancreatitis, and
metabolic complications of acute gastroenteritis, such
as electrolyte and acid base abnormalities.
When performed, laboratory testing should
include a complete blood count, serum biochemical
profi le, and urinalysis. Measurement of serum canine
pancreas-specifi c lipase concentration may also be
indicated to diagnose pancreatitis, and baseline serum
cortisol concentration may be measured in order to
exclude hypoadrenocorticism.
Additional laboratory testing for infectious disease
should be considered based on geographic location and FIGURE 1. Gastric nematode presumed to be
signalment. For example, serology assists in diagnosis Physaloptera rara visualized during gastroscopy.
of Salmon poisoning disease in the Pacifi c Northwest. The hemorrhage observed is associated with
In dogs with diarrhea, fecal fl otation and direct smear gastric biopsy.
examination should be performed to screen for primary
or concurrent parasitism (Figure 1).
In patients with clinical fi ndings (Table 2) or
laboratory results that suggest a serious underlying
cause, or those that do not respond to therapy,
further diagnostic evaluation is indicated. Early
identifi cation is especially important in patients
requiring surgical intervention, such as those with an
obstructive intestinal foreign body (Figure 2).

Imaging
Abdominal ultrasonography and/or abdominal learn More
radiography are strongly advised in patients Turn to page 77 to
presenting with abdominal pain to screen for diseases read the article,
Endoscopic Foreign
requiring surgical intervention. It is important to Body Retrieval.
FIGURE 2. Fabric gastric foreign body visualized
Table 2. during gastroscopy.
Selected Clinical Findings That Indicate
Further Diagnostic Evaluation in Dogs &
remember that pancreas-specifi c lipase concentrations
Cats with Acute Vomiting and/or Diarrhea
can be increased in dogs and cats with gastrointestinal
• Abdominal pain
foreign bodies. Therefore, it is essential to rule out
• Anorexia
• Bradycardia gastrointestinal foreign bodies with abdominal
• Chronic vomiting or diarrhea radiographs and, possibly, abdominal ultrasound
• Hematemesis before pancreatitis is diagnosed. If there is high
• Hyperthermia or fever
• Jaundice suspicion for a gastrointestinal foreign body that
• Lack of current vaccinations may have been obscured by fl uid or gas, diagnostic
• Lymphadenopathy imaging should be repeated.
• Masses or organomegaly on abdominal palpation
• Melena
• Polyuria/polydipsia THERAPEUTIC APPROACH
• Tachycardia When acute gastroenteritis is the primary cause
• Tachypnea, cough, or abnormal lung sounds
• Weak pulses of vomiting and/or diarrhea, the symptomatic
• Weakness treatments discussed in this article are appropriate
• Weight loss for therapy. However, if gastroenteritis occurs

tvpjournal.com | November/December 2015 | TODAy’S VETERINARy PRACTICE 47

Peer Reviewed Symptomatic Management of Primary Acute Gastroenteritis

secondary to an underlying disease, such as Ondansetron & Dolasetron

hypoadrenocorticism, it is essential to treat the
primary condition in addition to providing
symptomatic and supportive therapy.
This article emphasizes symptomatic treatment of
primary acute gastroenteritis rather than detailing
specific treatment of serious underlying diseases that
may cause similar clinical signs.
Ondansetron and dolasetron are serotonin (5-HT3)
antagonists with potent antiemetic activity that are
commonly used off-label to control nausea in dogs
and cats. This class of drug blocks the chemoreceptor
trigger zone and vagal afferent pathways involved
in emesis. In our experience, these drugs are very
effective for control of vomiting in dogs and cats.

ANTIEMETIC DRUGS Maropitant

For acute gastroenteritis, antiemetic therapy is often
used for the initial 24 to 48 hours when vomiting is a
prominent clinical sign (Table 3). Benefits include:
• Improved patient comfort
• Decreased ongoing fluid and electrolyte losses
• Earlier reintroduction of enteral nutrition
• Reduced risk of esophagitis and esophageal
stricture formation.
Take care not to mask ongoing disease with
prolonged (ie, greater than 3 days) antiemetic
therapy. In addition, to reduce the risk of
gastrointestinal perforation and avoid delay of
surgical intervention by masking clinical signs of
intestinal obstruction, do not administer antiemetic
or prokinetic drug therapy when a foreign body is
suspected or confirmed.
Several classes of antiemetic drugs are used in small
animal medicine. Occasionally, refractory cases require the
use of more than one of these drugs at the same time.
Substance P is a neurotransmitter that binds to
neurokinin-1 (NK-1) receptors and can result in
vomiting. Therefore, NK-1 receptor antagonists
are powerful antiemetics effective at treating both
peripheral and central causes of vomiting.
Maropitant, a NK-1 receptor antagonist, is
currently the only licensed antiemetic for use in dogs
and cats and, in our opinion, is very effective. This
drug may also have an analgesic effect and, thus, is
widely used in patients with vomiting and abdominal
pain, such as those with pancreatitis.1 The efficacy
of maropitant for the control of presumed nausea is
controversial as some studies have shown a benefit
while others have not documented a benefit.2-6
While maropitant is not licensed for IV use, we
and other clinicians have administered it by this
route—at a dose of 1 mg/kg Q 24 H—without
apparent adverse effects. The manufacturer
recommends that after 5 days of continuous

Table 3.
Medical Therapy for Vomiting Due to Acute Gastroenteritis
DRUG DOGS CATS

Antiemetics
Ondansetron 0.1–1 mg/kg PO Q 12–24 H 0.1–1 mg/kg PO or IV Q 12–24 H
Dolasetron 0.5–1 mg/kg IV Q 12 H 0.6 mg/kg IV Q 12 H
Maropitant 1 mg/kg SC Q 24 H 1 mg/kg SC Q 24 H
2 mg/kg PO Q 24 H 2 mg/kg PO Q 24 H
1 mg/kg IV Q 24 Ha 1 mg/kg IV Q 24 Ha
Metoclopramide 0.2 mg/kg SC or PO Q 8 H 0.2–0.4 mg/kg PO or SC Q 6–8 H
1–2 mg/kg/H IV CRI 1–2 mg/kg/H IV CRI

Gastroprotectants
Sucralfate 0.5–1 g PO Q 8–12 H (tablet or slurry)b 0.5 g PO Q 8–12 H (tablet or slurry)b
Famotidine 1 mg/kg PO or IV Q 12 H 1 mg/kg PO or IV Q 12 H
Omeprazole 1 mg/kg PO Q 12 H 1 mg/kg PO Q 12 H
Pantoprazole 1 mg/kg IV Q 24 H 1 mg/kg IV Q 24 H
Misoprostol 2–5 mcg/kg PO Q 8–12 H Not applicable
a. Not a manufacturer recommended route of administration
b. Potential reduced risk of emesis if administered as a slurry

48 Today’s Veterinary Practice | November/December 2015 | tvpjournal.com

 Symptomatic Management of Primary Acute Gastroenteritis
administration the drug should be discontinued for
24 hours to avoid drug accumulation; then treatment
can be restarted, if necessary.
Metoclopramide
Antidopaminergic agents, such as metoclopramide,
have both central and peripheral antiemetic
effects and are used off-label in dogs and cats.
Metoclopramide also stimulates the release of
acetylcholine from postganglionic nerves in the
peripheral nervous system, which leads to increased
gastric contractions and increased gastroesophageal
sphincter tone. This promotility effect may also
contribute to its antiemetic properties.
Metoclopramide can cause neurologic side effects,
including excitement and restlessness. The short
half-life of this drug necessitates frequent dosing. In
our experience, it is most effective when delivered
via an IV constant rate infusion but is not as
effective as maropitant, ondansetron, or dolasetron.
Metoclopramide may not have a direct central
antiemetic effect and is a less effective antiemetic
agent in cats than in dogs.7 For this reason, we
seldom use it for this purpose in the former unless a
prokinetic agent is also indicated.
Phenothiazines
Phenothiazines, such as chlorpromazine and
prochlorperazine, are potent centrally acting
antidopaminergics that inhibit the vomiting center and
chemoreceptor trigger zone. This class of drug also has
antihistaminergic and anticholinergic properties.8
They are not recommended in hypovolemic
patients due to potential for hypotension, and these
drugs are not licensed for use in dogs and cats.
Phenothiazines can cause mild sedation and are no
longer commonly used due to the availability of other
effective antiemetic drugs.
GASTROPROTECTANTS
Sucralfate
Sucralfate is a sulfated disaccharide that binds to
the acidic moieties of exposed collagen in damaged
mucosa, creating a protective barrier against further
acid damage. It also stimulates prostaglandin release
and cellular proliferation at sites of ulceration and
increases mucus production and bicarbonate secretion.
Sucralfate is recommended only in cases of suspected
gastrointestinal erosion or ulceration, such as those that
present with hematemesis or melena. It can interfere
with absorption of other drugs, and is typically given at
least 2 hours before or after other medications.
tvpjournal.com | November/December 2015 | Today’s Veterinary Practice
Peer Reviewed
Famotidine & Ranitidine
Famotidine and ranitidine are histamine-2 (H2)-
receptor antagonists that competitively inhibit
histamine-induced acid secretion by the gastric
parietal cells.
Famotidine is more effective at increasing
canine gastric pH compared with ranitidine, but
ranitidine also has anticholinesterase activity. This
activity may result in some prokinetic action but in
studies was only as effective as a saline placebo at
increasing gastric pH in dogs and cats; thus, it is not
recommended for its acid-suppressing effects.9,10
H2-receptor antagonists are less efficacious than
proton pump inhibitors (PPIs) in vivo, but the degree
of gastric acid inhibition necessary for therapeutic
effect is unknown. H2-receptor antagonists may also
have cytoprotective properties.11,12
Omeprazole & Pantoprazole
Omeprazole and pantoprazole are PPIs that
irreversibly inhibit acid production by gastric parietal
cells. This class of drug is more efficacious and
has a longer duration of activity than H2-receptor
antagonists; it may also exert a cytoprotective effect
by enhancing prostaglandin synthesis.9-11,13
In dogs and cats, twice-daily dosing of
omeprazole is more effective at reducing gastric
acid secretion than once-daily administration.9,10
Coadministration of famotidine and pantoprazole
does not seem to be any more effective than therapy
with pantoprazole alone and, thus, there is no
benefit in using a H2-receptor antagonist for the first
24 hours of therapy.14
Because of this, PPIs are the preferred treatment
for dogs and cats known or suspected to have
esophageal or gastroduodenal ulceration.11,14
Anecdotally, some dogs and cats with acute
gastroenteritis, but no other findings that indicate
gastroduodenal ulceration, such as hematemesis
or melena, appear to respond favorably to acid-
suppressing drugs. However, use of these drugs has
not proven beneficial in any studies in dogs and cats
with uncomplicated gastroenteritis; thus, they are not
routinely recommended for brief episodes.
In humans, long-term use of PPIs has been
associated with such side effects as cobalamin
deficiency, iron deficiency, hypomagnesemia,
increased susceptibility to pneumonia, enteric
infections, fractures, hypergastrinemia, and
cancer.15 To our knowledge, other than
hypergastrinemia, the side effects described above
have not been reported in dogs and cats receiving
long-term treatment with PPIs.
49
Peer Reviewed Symptomatic Management of Primary Acute Gastroenteritis
Misoprostol
Misoprostol is a synthetic prostaglandin E1 that
acts on parietal cells to inhibit secretion of gastric
acid. Additionally, it has a cytoprotective effect by
increasing secretion of mucus by gastric goblet cells,
increasing gastric mucosal blood flow and increasing
turnover of gastric mucosal cells.
PPIs and H2-receptor antagonists are thought to
be more effective for treatment of gastrointestinal
ulcers, and misoprostol may cause vomiting, diarrhea,
and abdominal pain. Use of misoprostol is, therefore,
not advised in dogs with acute gastroenteritis
unless gastroduodenal ulceration associated with
nonsteroidal anti-inflammatory drug (NSAID) use is
thought to be the cause.
ANTIDIARRHEAL THERAPY
Most cases of uncomplicated acute gastroenteritis
that present with either small or large bowel diarrhea
resolve without therapeutic intervention. Cases that
present with diarrhea should have a fecal examination
and consider empirical deworming with a broad
spectrum anthelminthic. However, there are a few
options for symptomatic treatment of diarrhea.
Loperamide
Loperamide, an opioid antimotility drug, has been
used off-label in dogs with diarrhea. It decreases
intestinal motility and reduces mucosal secretions.
Doses used to treat diarrhea can cause neurologic
toxicity in dogs with the ABCB1 (formerly MDR1)
mutation; therefore, avoid this drug in all dogs
carrying this allele and at-risk dog breeds (ie,
Australian shepherd, Shetland sheepdog, long-haired
whippet, collie, English shepherd, German shepherd)
that have an unknown status. We do not recommend
use of this drug for treating dogs or cats with acute
gastroenteritis due to this potential toxicity and
because the diarrhea associated with gastroenteritis is
usually self-limiting.
Probiotics
Probiotics are live microorganisms that confer a
health benefit on the host.16 These health effects
are exerted by direct inhibition of colonization
by pathogenic microorganisms, or by immune-
enhancing effects on gut-associated lymphoid
tissue.17-19
Probiotics (Table 4) are sometimes used to treat
dogs and cats with acute diarrhea. Each probiotic has
a different formulation of bacteria, and it is unknown
which, if any, are most useful for treatment of acute
gastroenteritis with resultant diarrhea. Therefore,
50 Today’s Veterinary Practice | November/December 2015 | tvpjournal.com
Table 4.
Examples of Commercial Probiotics for
Dogs & Cats
• FortiFlora (purina.com)
• Prostora (iams.com)
• Proviable (nutramaxlabs.com)
• Sivoy (sivoy.net)
further study of these products is needed before
definitive recommendations can be made.
The efficacy of some probiotics for treatment of
chronic diarrhea in dogs and cats has been evaluated
but, to our knowledge, there have only been 2 studies
evaluating the efficacy of probiotics in dogs with
acute diarrhea; both found that probiotics decreased
the duration of diarrhea in dogs with acute idiopathic
diarrhea.20-23
When selecting a probiotic, it is important to
choose a product that has been subjected to adequate
quality control during the manufacturing process,
such as the ones listed in Table 4.
Antimicrobial Therapy
Antimicrobial therapy with metronidazole or tylosin
is sometimes used empirically in dogs and cats with
idiopathic acute gastroenteritis that present with
either small or large bowel diarrhea. Both antibiotics
are used to potentially treat specific bacteria that
may cause acute gastroenteritis (eg, Clostridium
perfringens).
However, a study evaluating the efficacy of
amoxicillin/clavulanic acid in dogs with acute
hemorrhagic diarrhea syndrome (formerly called
hemorrhagic gastroenteritis) demonstrated no benefit
in treated dogs versus control dogs.24 Therefore,
routine antibiotic therapy (including the use of
metronidazole) is not recommended in dogs or cats
with acute gastroenteritis.
Antibiotic therapy may have a role in dogs and cats
suspected to have bacterial translocation through a
damaged gastrointestinal mucosal barrier, and this
is potentially more likely in cases of gastrointestinal
bleeding. However, we reserve antimicrobial therapy
for patients with:
• More definitive evidence of translocation, such as
leukocytosis, elevated immature white blood cell
count, and pyrexia
• Leukopenia or those that are immunosuppressed
• A specific bacterial enteropathogen (eg,
campylobacteriosis)
• Chronic diarrhea (as a therapeutic trial to rule out
dysbiosis).
 SyMPTOMATIC MANAGEMENT OF PRIMARy ACUTE GASTROENTERITIS Peer Reviewed

NUTRITIONAL MANAGEMENT added dietary fi ber experienced signifi cant clinical

Fasting improvement compared with dogs fed diets without
The concept of complete fasting has been questioned added fi ber.25
in recent years for dogs with acute gastroenteritis.
Complete restriction of food may be reasonable for a FLUID THERAPY
short period, but an early return to appropriate oral Acute gastroenteritis can lead to fl uid losses and
intake is advised unless contraindicated, such as in electrolyte imbalances that necessitate fl uid therapy.
cases suspected to have foreign bodies.
Subcutaneous Therapy
Diet Considerations SC fl uid therapy may be appropriate for mild
A wide variety of commercially available diets is dehydration or when outpatient therapy is
marketed for dogs and cats with gastroenteritis. Each elected due to fi nancial concerns; however, it
is formulated with slightly different protein and would be considered inappropriate for signifi cant
carbohydrate sources and fat content; some contain
dehydration or hypovolemia. SC fl uids should not
other potentially benefi cial constituents, such as
be supplemented with dextrose because bacterial
fructooligosaccharides or omega-3 fatty acids.
contamination and cellulitis can develop. Where
Cats should receive enteral nutrition as soon as
supplementation with dextrose is needed IV
possible to avoid protein calorie malnutrition, which
administration is preferable.
can lead to feline hepatic lipidosis. A commercially
available, highly digestible diet is recommended. The
Oral Therapy
goal of feeding a highly digestible diet is to reduce
Oral electrolyte solutions can be used in cases of
the risk for malabsorption.
mild dehydration. In a recent study, this route of
administration was safe and effective in dogs with
Dietary Fiber
hemorrhagic diarrhea.26
For patients with large bowel diarrhea, dietary fi ber
is an important component of dietary management.
While the optimal amount and type of dietary Intravenous Therapy
fi ber for treatment of dogs and cats with acute Goal-directed, targeted IV fl uid therapy to correct
gastroenteritis are not known, there is general an estimated percent dehydration over a specifi c time
agreement that, in dogs and cats: frame and to achieve normovolemia is recommended
• Dietary fermentable fiber enhances normal colonic for moderate to severe dehydration or hypovolemia.
function by providing a fuel source for colonocytes Balanced replacement crystalloid solutions, such as
• Dietary nonfermentable fiber increases fecal bulk, lactated Ringer’s solution, are an appropriate choice
which promotes normalized colonic motor in most patients. Ongoing monitoring of serum
function and defecation. electrolyte concentrations is recommended because
Potential sources include canned pumpkin, brown supplementation is sometimes required.
rice, peas, and carrots. There are no established
guidelines for fi ber supplementation in cases of small H2 = histamine-2; NK-1 = neurokinin-1; NSAID =
bowel diarrhea. nonsteroidal anti-infl ammatory drug; PPI = proton
In one study, dogs with colitis that received pump inhibitor

YURI LAWRENCE JONATHAN LIDBURY

Yuri Lawrence, DVM, MA, MS, Diplomate
ACVIM (Small Animal Internal Medicine),
is enrolled in the Texas A&M University
Gastrointestinal PhD program and also serves
as a senior clinician at the institution’s small
animal hospital. Dr. Lawrence received his
DVM from Tufts University; then completed
an MA in anatomy and neurobiology at
Boston University, internship in small animal
medicine and surgery at North Carolina State
University, and residency in small animal
internal medicine and MS in veterinary
science at Oregon State University.
Jonathan Lidbury, BVMS, MRCVS,
Diplomate ACVIM (Small Animal Inter-
nal Medicine) & ECVIM (Companion
Animal), is an assistant professor of vet-
erinary small animal internal medicine
at Texas A&M University. Dr. Lidbury
received his BVMS from University of
Glasgow in Scotland and completed
his small animal internal medicine res-
idency at Texas A&M University. His
clinical and research interests include
small animal hepatology and gastro-
enterology.

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Peer Reviewed Primary Acute Gastroenteritis

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