In my last post I discussed the options available when collecting intestinal biopsy samples. While both flexible endoscopic samples and laparoscopic assisted intestinal biopsy have their benefits, it really does come down to individual expectations and suspicion of disease(s). In this post, I thought I would summarize 2 cases that I participated in during a visit to a local hospital. I think it is important to remember that both rigid and flexible endoscopic samples would have been appropriate procedures for both of these procedures, however we used a case based approach to determine what we considered the best option.
"Jolene" is a 9 year old, female spayed Schnauzer with a chronic history of diarrhea and weight loss with intermittent vomiting. Previous diagnostics had not helped isolate a cause, nor had symptomatic treatment and multiple diet changes. As the disease progressed and Jolene continued to lose weight, her regular veterinarian became concerned about the possibility of Inflammatory Bowel Disease (IBD) or Intestinal Lymphoma (a form of cancer). Jolene's regular vet recommended intestinal biopsy and we discussed the best approach to take. In this case, we elected to perform upper and lower GI endoscopy (flexible) and collect biopsy samples from all areas of the GI tract (stomach, duodenum, jejunum, ileum, and colon). Multiple samples were collected throughout and sent to the lab for interpretation. A diagnosis of Inflammatory Bowel Disease was made based on these samples and appropriate therapy was initiated. Today Jolene is doing much better, has gained some weight back and her diarrhea is largely under control.
In Jolene's case, we were collecting samples from all areas of the GI tract, so flexible endoscopy made sense as full thickness biopsies of the colon are not generally recommended. The preparation required prior to a colonoscopy was reasonable and allowed us to biopsy the colon as well as the Ileum (most distal portion of the small intestine).
"Rex" is a 12 year old, male neutered Domestic Shorthair Cat with a history of vomiting and weight loss. As with Case #1, previous diagnostics had not isolated the potential cause. Previous diagnostics included bloodwork and urinalysis, radiographs, and an abdominal ultrasound. The ultrasound report indicated areas of thickening in the small intestine with a normal stomach. The 2 primary rule outs at this point were Inflammatory Bowel Disease (IBD) or Intestinal Lymphoma (cancer). Rex's regular veterinarian recommended intestinal biopsy and we discussed the best approach to take. In contrast to Case #1, we did not feel that biopsies of the colon were going to be especially helpful and agreed that good quality small intestinal biopsies were ideal. For Rex we elected to perform laparoscopic assisted full thickness intestinal biopsies and collected samples from the proximal duodenum along to the distal Ileum. These samples were sent to the lab and unfortunately a diagnosis of Intestinal Lymphoma was made. Rex was started on supportive care as the owners elected not to proceed with chemotherapy.
To better appreciate why this approach was made, it should be noted that the only way to collect samples of the Ileum using flexible endoscopy is via colonoscopy. The flexible scope, while quite long, is not long enough to travel to the Ileum all the way from the mouth. Therefore, a colonoscopy must be performed to biopsy the Ileum. Current literature suggests that the Ileum is the most ideal location to collect intestinal biopsy samples from if trying to differentiate IBD from Lymphoma. While we could have collected our samples using flexible endoscopy here, it would have required additional time and preparation (for the colonoscopy).
As I mentioned initially, it would have been reasonable to perform either type of minimally invasive procedure for each of these cases. However, by using a case based approach we were able to select the least invasive option that allowed a diagnosis to be made and more targeted treatments to be initiated.