Gastrointestinal endoscopy in dogs
Endoscopy is now widely available for the investigation of gastrointestinal disease in dogs; Franck Jolivet and Olivier Dossin present a practical, case-based paper that illustrates the versatility of the endoscope, along with some useful tips on how to best use this diagnostic option in practice.
Endoscopy is a safe and effective tool in canine gastroenterology, but it is only one component of the diagnostic work-up and should be used only when appropriately indicated.
Bi-directional endoscopy is always recommended when investigating dogs with chronic intestinal disease.
The clinician should decide if surgical or endoscopic biopsies are preferable for each case.
It is essential to take an adequate number of endoscopic biopsies in order to ensure an accurate histopathological diagnosis.
Endoscopy is a versatile and minimally invasive technique used to visualize the gastrointestinal (GI) lumen, perform biopsies for further analysis such as histopathology or bacterial analysis, and to deliver treatment for problems such as strictures, polyps or foreign body removal. Although complications of routine endoscopic procedures are rare 1, endoscopy must be performed after a thorough workup and should never be a substitute for a complete history, physical examination, appropriate laboratory procedures and other diagnostic imaging. It is especially important to note that endoscopy and endoscopic biopsy are not always indicated, especially in animals with chronic GI disease, without appropriate therapeutic trials (e.g., deworming, dietary modification, antimicrobial trial). In conjunction with other diagnostic modalities, endoscopy can be both a powerful diagnostic tool for many GI disorders in dogs and an invaluable therapeutic tool, particularly for the retrieval of gastric or esophageal foreign bodies.
This article will consider the benefits of endoscopy in dogs using five case studies. Interventional endoscopy and laparoscopy are beyond the scope of this paper.
Standard GI videoendoscopy equipment consists of a flexible endoscope, a light source, a videoprocessor, a monitor and an air pump; a videorecording system is frequently connected to the system 2 3. A variety of instruments and accessories are also available, including biopsy forceps, cytology brushes, aspiration/injection needles and foreign body forceps/baskets 4. The main considerations when choosing an endoscope are its length, the outer diameter of the scope, and the diameter of the accessory channel. In dogs, a scope of 8-9 mm diameter and 100-140 cm in length is the most versatile for routine GI endoscopy 2 5, although in the largest breeds this might be too short to pass the ileo-colonic sphincter or the pylorus. It is usually better to select a scope with an accessory channel with a 2.8 mm diameter, which will accept the largest biopsy forceps; this enables a better biopsy quality.
Endoscopic findings should be recorded (ideally including pictures) immediately after the procedure, and standardized reporting forms have been recently proposed (see: www.wsava.org/guidelines/gastrointestinal-guidelines).
Indication and patient preparation
The clinical signs of esophageal disease include regurgitation, dysphagia, hypersalivation, coughing, anorexia, and halitosis. Esophageal endoscopic examination should only be performed after obtaining a thorough history, physical examination, thoracic radiographs (including contrast studies if appropriate), and (where indicated) fluoroscopic examination 6. Esophageal endoscopy, sometimes with biopsy, can offer additional information for the diagnosis of foreign bodies (Box 1), strictures (Box 2), esophagitis, granuloma associated with Spirocera lupi, and neoplasia. The healthy esophagus is usually very difficult to biopsy and, in general, if samples can be taken easily it means that the esophageal mucosa is abnormal. Esophageal endoscopy requires general anesthesia (ideally after 8-12 hours fasting), with the patient in left lateral or sternal recumbency. If motility is impaired, such that there is retention of food within the esophagus, a 24-hour fast (or even esophageal lavage after tracheal intubation) may be required to permit successful endoscopy.
Box 1. Esophageal foreign bodies in dogs.
Esophageal foreign bodies (FB) are frequent in dogs and are genuine emergencies. Rapid intervention is necessary because of the risk of severe complications; the longer a FB remains within the esophagus, the greater the risk. Diagnosis is usually via a combination of history, physical examination (drooling, anorexia, regurgitation of saliva) and thoracic radiography. Severe esophagitis can produce gagging or regurgitation/ vomiting, and respiratory complications such as aspiration pneumonia or pneumothorax may be present. The FB is located within the thoracic esophagus in the vast majority of cases, but abdominal radiography should always be performed to evaluate the rest of the GI tract. Endoscopic retrieval is the preferred method and is curative in 68-90% of cases, but if not successful the FB can usually be pushed into the stomach and surgically removed. However, if there is a risk of esophageal tear or where perforation has already occurred, esophagotomy is preferred, despite a higher risk of complications. During retrieval, it can help to change the dog’s position, but, in general, if endoscopic retrieval is not successful after 60-90 minutes it is probably wise to consider a surgical alternative. Complication of endoscopic retrieval (usually in around 10% of cases) include esophagitis and stricture formation, esophageal perforation and even laceration of adjacent organs such as the aorta, with bones most likely to cause complications. Dogs with more severe esophagitis after removal, or weighing < 10 kg, have a higher rate of complication, but surgical intervention has a higher complication rate than endoscopic retrieval.
Further reading: Gianella P, Pfammatter NS, Burgener IA. Oesophageal and gastric endoscopic foreign body removal: complications and follow-up of 102 dogs. J Small Anim Pract 2009;50:649-654.
Clinical signs of esophageal strictures are regurgitation of food, usually shortly after ingestion, sometimes associated with halitosis and ptyalism. Anorexia is rare unless odynophagia is present. Esophageal strictures develop as a complication of esophagitis, especially with gastroesophageal reflux (GER) during anesthesia, but also from esophageal FB retrieval or as a complication of esophageal surgery. Diagnosis is via plain or contrast radiography or by endoscopy. Treatment options include dilation under fluoroscopic or endoscopic guidance; dilation can be performed with a water-inflated balloon or with bougienage, but the latter option is more traumatic than the former. Following dilation triamcinolone can be injected via an endoscopic needle into the esophageal wall to help prevent recurrence, along with antibiotics, proton pump inhibitors and gastric protectants. Stenting has recently been proposed as an option for refractory strictures. Drugs such as omeprazole or esomeprazole can be used to increase the pH of the gastric contents in an attempt to prevent esophagitis and stricture formation secondary to general anesthesia. Fasting for too long before surgery has been associated with increased GER, suggesting that the ideal pre-operative fasting is 8-12 hours.
Further reading: Adamama-Moraitou KK, Rallis TS, Prassinos NN, Galatos AD. Benign esophageal stricture in the dog and cat: a retrospective study of 20 cases. Can J Vet Res 2002;66:55-59.
Contrast studies, especially using barium, should be avoided before endoscopy because this may impair visualization of the mucosa. If such studies are performed, endoscopy must be postponed for at least 24 hours.
Esophageal endoscopy is best undertaken with a flexible scope; rigid endoscopes may be used to remove large foreign bodies, but increase the risk of esophageal perforation and do not allow for extensive esophageal inspection.
An 11-month-old male Pug dog was referred for acute anorexia and regurgitation that had developed 3 days previously. Physical examination and bloodwork were unremarkable. Thoracic radiography identified an unusual opacity in the distal esophagus, strongly suggestive of a bony foreign body (Figure 1). Endoscopy revealed the esophagus to be dilated at the thoracic inlet, with a large bone embedded into the esophageal wall just cranial to the cardia (Figure 2). Despite altering the patient’s position several times, a prolonged endoscopic session failed to retrieve the foreign body, which was eventually pushed into the stomach. Subsequent endoscopic inspection revealed no gastric abnormalities, but considering the severe necrotic ulcerative esophageal lesions and the high risk of esophageal perforation, a gastrotomy was performed only two days later to retrieve the bone. Treatment with omeprazole, sucralfate, antibiotic and methylprednisolone was then administered for 10 days. A postoperative stricture was considered a possible complication, and if clinical signs had persisted a further endoscopic evaluation would have been undertaken, but recovery was uneventful and one year later the dog remained well.
A 9-month-old neutered female Labrador was referred with a history of chronic (one month) regurgitation/vomiting of food, invariably a few minutes after ingestion. Hypersalivation and severe weight loss over the last month were also reported. The dog’s appetite was good but she was unable to keep food down. The dog had been spayed one week before clinical signs appeared. On physical examination, her body condition score was 2/9, with moderate muscle atrophy and dehydration evaluated at 8%. The dog had ptyalism, and palpation of the ventral neck was painful. Bloodwork revealed minor hyperproteinemia, hypernatremia and hypochloremia, compatible with regurgitation/ hypersalivation. Radiography showed the rostral half of the thoracic esophagus to be dilated (Figure 3). With the dog anesthetized and in left lateral recumbency, endoscopy revealed a severe esophageal stricture (Figure 4), possibly secondary to gastroesophageal reflux during the recent anesthetic episode. The tip of the scope could not be passed through the stricture, but the lesion was successfully dilated using a balloon passed through the scope and inflated with water (Figure 5). Caudal to the stricture, severe multifocal ulceration was noted (Figure 6) but no abnormalities were seen within the stomach. In all, three balloon dilations (at intervals of 5- 6 days) were required to obtain satisfactory resolution of the stricture. After the second dilation, fluoroscopy with a barium meal was performed: esophageal motility was normal with moist food, whereas a dry food bolus could not pass the stricture without the dog swallowing water. No gastroesophageal reflux was observed during fluoroscopy. Omeprazole, sucralfate and methylprednisolone were prescribed between each stricture dilation and for two weeks after the last treatment. Three months after the last dilation, the patient was doing well and had gained weight, but only moistened kibble was tolerated, with dry kibble inducing regurgitation.
Indication and patient preparation
Clinical signs of gastric disease include vomiting, hematemesis, anorexia, nausea, halitosis and/or melena. Gastric endoscopy is particularly recommended for patients with chronic GI disease, but may also be indicated if an acute problem such as a gastric foreign body or ulceration is suspected 7. During the procedure, and especially when there are chronic GI signs, duodenal endoscopy should also be performed. For most cases with chronic vomiting, duodenal (rather than gastric) endoscopy and biopsy will actually provide the diagnosis. Gastric endoscopy with biopsy can typically assist in the diagnosis of gastritis, neoplasia, chronic hypertrophic gastropathy, and ulcers, but (as previously mentioned) endoscopy should only be performed after a thorough work-up. Endoscopy can also enable foreign body retrieval and removal of polyps, or assist in placement of a feeding tube. Endoscopy requires general anesthesia (again ideally after fasting for at least 8-12 hours, and sometimes up to 24-36 hours if delayed gastric emptying is suspected), with the dog placed in left lateral recumbency for the procedure. Contrast studies, especially if using barium, must be performed at least 24-36 hours before endoscopy, as barium can impair visualization of the mucosa and also damage the scope. If necessary, abdominal radiography can be performed before endoscopy to evaluate for residual barium. The main limitation of gastric endoscopy is that it cannot diagnose submucosal disease and GI motility disorders. In addition, the size or shape of some foreign bodies can mean that endoscopic retrieval is impossible, and removal of large trichobezoars can also be very prolonged using a scope; in such cases, surgical removal may be a rational alternative.
A 12-year-old intact female Shih Tzu was referred with a history of vomiting daily for the last 9 months, unresponsive to empirical treatment (deworming, antibiotics, dietary trials, gastric protectants). Physical examination revealed a low body condition score (2/9) and 10% body weight loss over the last 3 months. Blood chemistry, CBC, urinalysis, cPL test, fecal parasite screening and thoracic radiography revealed no abnormalities, but folate and cobalamin were both severely decreased (folate was 2.59 ng/mL (reference interval: 5-12) and cobalamin < 150 ng/L (RI: 250-800)). Severe thickening of the gastric wall was noted on abdominal ultrasound, with a focal reaction in the mesenteric fat (Figure 7). Ultrasound-guided fine-needle aspiration of the stomach wall revealed a neutrophilic inflammation. Given the strong suspicion of neoplasia, gastric endoscopy was performed. The esophagus, stomach fundus and the greater curvature were normal, but the lesser curvature and the antrum were rigid and did not dilate on insufflation; there was no ulceration. The severity of the changes to the antrum meant that the scope could not be passed through the pylorus (Figure 8). Histopathology revealed a gastric adenocarcinoma with a very poor prognosis, and the dog was euthanized a few days later (Box 3).
Gastric adenocarcinoma accounts for 70-80% of all stomach cancers in dogs. The most common clinical signs are progressive and include vomiting, anorexia, weight loss and hematemesis, with a duration ranging from days to several months. Routine blood results can be non-specific but may include anemia and increased liver enzymes due to liver metastasis or obstruction of the common bile duct. Endoscopy can detect most, if not all, gastric carcinomas: typically a firm, non-distensible stomach is visualized, with lesions that can be diffusely infiltrative; these may be largely ulcerative with necrotic centers, or can be polypoid in nature. The pylorus and antrum are most likely to be involved, especially close to the angular notch. The definitive diagnosis is based on histopathology findings, but cytology of endoscopic biopsies or fine-needle aspirates retrieved at surgery can be useful. These two techniques correlate well with histopathology findings. A normal histopathological result on endoscopic biopsy may not rule out the presence of gastric cancer; indeed, if the neoplastic infiltration is located deeper in the mucosa, endoscopic biopsies may be too superficial, and the definitive diagnosis may require a full-thickness surgical biopsy. However, ultrasound examination is less invasive, and ultrasoundguided fine-needle aspiration of the gastric wall may be a good alternative. There is no specific therapy, unless complete excisional surgery can be performed before any metastatic spread, and the prognosis is usually poor, with a survival time < 6 months.
Further reading: Marolf AJ, Bachand AM, Sharber J, et al. Comparison of endoscopy and sonography findings in dogs and cats with histologically confirmed gastric neoplasia. J Small Anim Pract 2015;56:339-344.
Indication and patient preparation
Clinical signs of small intestinal disease include chronic or recurrent vomiting and/or diarrhea, abdominal pain, weight loss, GI bleeding (hematemesis, melena or anemia) or irregular appetite. After excluding systemic disease for dogs with weight loss and chronic diarrhea and/ or vomiting, the decision to perform endoscopic examination 8 is based on:
• The severity of the clinical signs, or if there is GI bleeding
• A non-response to empirical treatment (deworming, dietary modifications, antibiotic trial)
• Laboratory test results (hypoalbuminemia, positive fecal α1-antiprotease, low-serum cobalamin and/or folate with normal TLI)
• Abdominal ultrasound findings (intestinal wall changes or intestinal hyperechoic mucosal striations in a hypoalbuminemic dog 9
Surgical (rather than endoscopic) biopsy may be a better option for diagnosis in some cases, especially if abdominal ultrasound reveals a focal intestinal disease in a segment that cannot be reached by the scope, or if abnormalities are detected deep into the mucosa. Although the least invasive method for obtaining intestinal biopsies, there are certain situations where endoscopy may be contraindicated: e.g., severe clinical conditions such as hypovolemia, hypotension or coagulopathy, or where the patient is at increased risk for anesthesia. In these cases, depending on the clinician’s assessment, medical treatment may be employed to stabilize the patient and endoscopic examination can be delayed. Again, endoscopy should only be performed after a thorough work-up including ultrasound, fecal parasite screening, blood samples (including TLI, folate and cobalamin levels) and urinalysis. The two main limitations are that endoscopic biopsies are superficial and can only diagnose conditions affecting the mucosa, and that it can be difficult to pass the pylorus or the ileocolic sphincter in some patients. An “up-and-down” endoscopic approach is now recommended for dogs with chronic GI disease which require intestinal biopsies, because some diseases processes, including inflammation and lymphangiectasia, can be heterogeneously distributed along the small intestine 10 11. Recent studies have defined the minimal number of adequate endoscopic biopsies necessary to reach a diagnosis 12 13 14 (Table 1). Duodenal/ileal endoscopy requires general anesthesia, and the dog should be fasted for 8-12 hours beforehand and placed in left lateral recumbency; ileoscopy requires a longer fasting period and the preparation employed for colonoscopy (see below) should be followed.
|GI Segment||Number of endoscopic samples|
|Stomach||6 adequate biopsies; biopsy gastric body unless focal lesions present|
|Duodenum||10-15 adequate biopsies|
|Ileum||5 adequate biopsies|
|Colon||9-12 adequate biopsies, with at least 3-4 biopsies from each colonic region|
A 10-year-old female Border Collie was referred with chronic (3 months) mixed bowel diarrhea, with no response to empirical treatment. Other than a low body condition score, clinical examination was unremarkable. Blood samples revealed hypoalbuminemia (13.3 g/L (23-39)), hypomagnesemia (0.15 mmol/L (0.7-1.0)) and hypocobalaminemia (84 ng/L (200-800)). Bile acid tests, CBC, urinalysis, clotting panel, fecal parasite screening, and thoracic radiography did not reveal any abnormalities. On ultrasound, gastric motility was noted to be abnormal. Considering the severe hypoalbuminemia, bi-directional endoscopy (gastro-duodeno-ileo-colonoscopy) was performed after correcting the hypomagnesemia. Colonic endoscopy was normal. The scope was passed successfully through the ileocolic valve and revealed prominent villi, strongly suggestive of lacteal dilation (Figure 9). The esophagus and stomach were normal but the duodenal mucosa was friable, again with prominent villi. Biopsies were taken from all GI segments, revealing moderate duodenal inflammation and lymphangiectasia and severe changes in the ileum (Box 4). Prednisolone and metronidazole, combined with cobalamin supplementation and a hypoallergenic diet, were initiated. The dog showed both clinical and biochemical improvements within a few days; treatment was withdrawn after six weeks without recurrence of clinical signs.
Protein-losing enteropathy (PLE) is a syndrome associated with an abnormal loss of albumin through the GI tract. It may be associated with various disease conditions, mostly chronic intestinal inflammation and intestinal lymphangiectasia, but also intestinal lymphoma. The classical presentation is a combination of chronic, relapsing digestive signs associated with severe weight loss and dependent edema or body cavity effusion. Chronic diarrhea is the most common clinical sign, but is not seen in all cases. Other signs include chronic vomiting, respiratory distress secondary to pleural effusion, melena or other signs associated with complications of PLE such as thrombosis.
The diagnosis of PLE must be staged. Once hypoalbuminemia is confirmed, it is important to exclude other causes (e.g., liver disease, protein-losing nephropathy, Addison’s disease) using standard blood tests. Most, but not all, dogs with PLE also develop a concurrent hypoglobulinemia and hypocholesterolemia. Where available, a fecal alpha 1-antitrypsin measurement may be useful to confirm PLE in cases with concurrent protein-losing nephropathy or liver failure. The second step is abdominal ultrasonography in order to select the biopsy method (endoscopy vs. surgery) and to evaluate other abdominal organs. Ultrasound may identify focal or patchy lesions within the GI tract, and ultrasound-guided fine-needle aspiration of all abnormal organs can be useful if lymphoma is suspected. However, a normal abdominal ultrasound is never a reason to rule out intestinal disease. The third step is intestinal biopsy (endoscopic or surgical full thickness) and histopathological diagnosis.
Endoscopy is not always recommended, especially if lesions are located in a segment inaccessible to endoscopy, but, if performed, a bi-directional procedure (upper and lower gastrointestinal) is always recommended to allow biopsy of the duodenum and the ileum, as lesions can be distributed in a patchy or segmental pattern.
Further reading: Dossin O, Lavoué R. Protein-losing entero pathies in dogs. Vet Clin North Am Small Anim Pract 2011;41:399-418.
Indication and patient preparation
Clinical signs of colonic disease include especially signs of large bowel diarrhea, e.g., diarrhea with tenesmus, dyschezia, mucus, and hematochezia. Other signs of colonic disease include vomiting, constipation, hematochezia without diarrhea and mixed bowel diarrhea. Vomiting may be seen in up to 30% of colonic disease cases, and hematochezia without diarrhea is reported in 70% of dogs with rectal tumors 15. Colonic endoscopy requires general anesthesia, again with the dog in left lateral recumbency. Patient preparation involves complete rectal and colonic fecal evacuation, partly because residual fecal material impairs visualization and may prevent complete examination up to the ileo-colonic sphincter, and partly because ileal scoping is now recognized as an essential part of the endoscopic work-up in patients with small bowel signs 16. There are various ways to prepare the patient; the authors prefer a two-stage protocol:
• The dog must only be fed a low-residue diet (e.g., boiled chicken or white fish) for 4-5 days before endoscopy.
• The patient is hospitalized the day before the procedure and fasted; enemas are administered 24 and 12 hours prior to colonoscopy, with a third enema just before the dog is anesthetized.
Each enema should be performed with 30-50 mL/kg of warm water, without soap. Other type of enema solutions (e.g., sodium phosphate) are not recommended, as life-threatening metabolic disorders with severe hypernatremia, hypocalcemia, hyperphosphatemia, and polycythemia have been reported 17. One study suggested that polyethylene glycol (PEG)-containing electrolyte solution given orally is preferable to administration of multiple enemas when preparing dogs for colonoscopy 18. However, large volumes of PEG are required (> 50 mL/kg) which can be difficult to administer, often necessitating nasogastric or orogastric intubation.
A 9-month-old male Boxer was referred for chronic large bowel diarrhea with hematochezia, tenesmus, and fecal mucus for 5 months, with no response to empirical treatment (fenbendazole, toltrazuril, metronidazole, enrofloxacin). Initially, the entire litter had shown the same signs, but the other puppies had improved when treated with enrofloxacin. No weight loss or failure to grow was noted, and the dog was correctly vaccinated and dewormed. There was no abnormality on physical examination, including rectal examination. Fecal parasite screening, CBC, biochemistry, TLI/folate/cobalamin levels, and urinalysis were normal. Abdominal ultrasound revealed submucosal vessels, with several disseminated nodules and petechiae in the descending colon (Figure 10). These findings were suggestive of severe colonic inflammation or (less likely) neoplasia; the dog’s age and breed suggested that granulomatous colitis was the most likely diagnosis, and this was confirmed on biopsy (Box 5). Enrofloxacin was prescribed for 6 weeks, along with a hypoallergenic diet, and the patient dramatically improved within 5 days; no relapse has been reported several years after the diagnosis.
Granulomatous colitis is an uncommon type of inflammatory bowel disease caused by an adherent, invasive species of Escherichia coli. Clinical signs are typical of large bowel diarrhea and weight loss, progressing to cachexia in severe cases. Boxers < 4 years are predisposed, but other breeds can be affected. Diagnosis is via endoscopic biopsy of the colon, with histology typically revealing severe mucosal ulceration and infiltration of the submucosa and lamina propria with macrophages that stain positive with Periodic Acid Schiff. The infectious cause may be identified by Fluorescence InSitu Hybridization (FISH), but a negative FISH result does not rule out E. coli, because bacterial invasion of the intestinal tissue can be patchy; a minimum of 10 mucosal biopsies is always recommended. Enrofloxacin (5- 10 mg/kg Q24 h for 6-8 weeks, even if the signs disappear quickly) is the preferred treatment and can achieve long-term remission, but bacterial culture of the biopsy (along with sensitivity testing) is recommended because quinolone resistance has been recently reported, associated with a poor clinical outcome. Enrofloxacin should not be prescribed for canine colitis before a definitive histopathological diagnosis of granulomatous colitis has been made.
Further reading: Craven M, Mansfield CS, Simpson KW. Granulomatous colitis of boxer dogs. Vet Clin North Am Small Anim Pract 2011;41:433-445.
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- Gaschen L, Kircher P, Stussi A, et al. Comparison of ultrasonographic findings with clinical activity index (CIBDAI) and diagnosis in dogs with chronic enteropathies. Vet Radiol Ultrasound 2008;49:56-64.
- Casamian-Sorrosal D, Willard MD, Murray JK, et al. Comparison of histopathologic findings in biopsies from the duodenum and ileum of dogs with enteropathy. J Vet Intern Med 2010;24:80-83.
- Procoli F, Motskula PF, Keyte SV, et al. Comparison of histopathologic findings in duodenal and ileal endoscopic biopsies in dogs with chronic small intestinal enteropathies. J Vet Intern Med 2013;27:268-274.
- Jergens AE, Willard MD, Allenspach K. Maximizing the diagnostic utility of endoscopic biopsy in dogs and cats with gastrointestinal disease. Vet J 2016;214:50-60.
- Willard MD, Mansell J, Fosgate GT, et al. Effect of sample quality on the sensitivity of endoscopic biopsy for detecting gastric and duodenal lesions in dogs and cats. J Vet Intern Med 2008;22;1084-1089.
- Willard MD, Moore GE, Denton BD, et al. Effect of tissue processing on assessment of endoscopic intestinal biopsies in dogs and cats. J Vet Intern Med 2010;24:84-89.
- Danova NA, Robles-Emanuelli JC, Bjorling DE. Surgical excision of primary canine rectal tumors by an anal approach in twenty-three dogs. Vet Surg 2006;35:337-340.
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- Tomsa K, Steffen F, Glaus T. Life-threatening metabolic disorders after application of a sodium phosphate containing enema in the dog and cat. Schweiz Arch Tierheilkd 2001;143:257-261.
- Richter KP, Cleveland MB. Comparison of an orally administered gastrointestinal lavage solution with traditional enema administration as preparation for colonoscopy in dogs. J Am Vet Med Assoc 1989;195: 1727-1731.
Olivier Dossin received his veterinary medicine degree from the Veterinary School of Toulouse. He worked for some 15 years as a faculty member Read more
After graduating from the University of Toulouse in 2013 and completing a rotating internship in Small Animal Medicine and Surgery, Dr Jolivet worked Read more