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When Diarrhea Turns Dangerous
Understanding hemorrhagic gastroenteritis
After four days of intensive care, this HGE-sufferer named Sam made a full recovery.

One of the more common problems I see on an emergency basis is a disease process called hemorrhagic gastroenteritis, also known as HGE. I recently treated Sam, the little Beagle in the photo, for a severe case of this disease.

The history I hear from owners is always the same: “My dog started having diarrhea and then, all of a sudden, it became very watery and bloody.” This can be horrifying to first-time observers and usually prompts a trip to the ER.

Hemorrhagic gastroenteritis is a potentially life-threatening intestinal condition, which manifests as a sudden onset of bloody, watery diarrhea, with vomiting often being part of the syndrome. Sloughing of the lining of the intestines occurs from severe inflammation leading to “chunks” of tissue in the otherwise watery stool. We describe this as “raspberry jam” diarrhea. This process is extremely dehydrating—much more than you would think from the amount of diarrhea observed—and dogs can go from “near normal” to “near death“ in a frighteningly short time. If HGE is not promptly treated, the massive loss of fluid can cause life-threatening shock.

Smaller dogs seem to have a predisposition towards HGE, and it should be noted that the smaller the dog, the more dangerous the condition. Small dogs just don’t have the same bodily reserve as a larger dog; it simply doesn’t take much for them to become severely dehydrated. 

Thankfully, there are no long-lasting bodily effects of HGE, however, some dogs that have sensitive GI tracts to begin with can have the syndrome recur in the future.

What causes HGE?

Stress, sudden dietary changes and hyperactivity seem to be predisposing factors, but the actual cause remains unknown. A bacterium called Clostridium is also thought to play a role. In short, the condition is truly another medical mystery, and I can relate to an owner’s confusion and frustration when they ask, “Yeah, but what actually caused it?” I cannot point to an exact cause in more than 80 percent of HGE cases I treat.

How is this condition diagnosed?

There are no specific tests for HGE but a test called a packed cell volume (PCV) is helpful in narrowing down the diagnosis. Using a few drops of blood, the test measures the percentage of blood volume made up by the red blood cells. A normal packed cell volume for a healthy dog is between 37 and 55 percent, meaning that 37 to 55 percent of the blood volume should be red blood cells (the rest of the volume is fluid and white blood cells).

When the patient becomes very dehydrated, there is less fluid in the bloodstream and the percentage of blood fluid drops, and consequently the percentage of red blood cells increases. A dog with HGE will generally have a PCV greater than 60 percent.

The measurement of the PCV also includes a measurement of total protein (sometimes called total solids). In HGE, the total protein measurement from the blood sample is low or normal.

A very high PCV, low total protein and acute onset bloody, watery diarrhea can point to a diagnosis of HGE.

From a medical standpoint, one of the things that makes diarrhea difficult is that no matter what the underlying cause, the clinical picture looks exactly the same. Because of this, we may still recommend that additional tests, such as radiographs, a fecal exam (that includes a parvovirus test) and blood work, be performed to make sure there is not a more serious problem causing the clinical signs.

HGE really becomes a diagnosis of exclusion: When blood work, radiographs and fecal exams are normal, we highly suspect HGE as the cause.

What is the treatment for HGE?

The heart of therapy is very aggressive fluid replacement with intravenous fluids. The goal is to get the packed cell volume back to the normal range and keep (or get) the patient out of shock. Food is withheld for at least 12 to 24 hours and then gradually introduced after the vomiting has resolved. Symptomatic treatment for nausea and belly discomfort is typically included, as is antibiotic therapy. One to three days of hospitalization is commonly required for treatment.

With early and aggressive treatment, life-threatening complications are generally avoided and dogs return happily home. In the case of Sam, he unfortunately required four days of intensive care, including nutritional support through a feeding tube as pictured, but I am happy to report that he made a full recovery and went back home to Mom and Dad!

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Veterinarian Shea Cox has enjoyed an indirect path through her professional life, initially obtaining degrees in fine arts and nursing. She later obtained her veterinary medical degree from Michigan State University in 2001 and has been practicing emergency and critical care medicine solely since that time. In 2006, she joined the ER staff at PETS Referral Center in Berkeley and cannot imagine a more rewarding and fulfilling place to spend her working hours. In her spare time, she loves to paint, wield her green thumb, cook up a storm and sail. Her days are shared with the three loves of her life: her husband Scott and their two Doberman children that curiously occupy opposite ends of the personality spectrum.

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Submitted by Kathleen St John | February 17 2012 |

HGE is some scary stuff. I've encountered it twice in my life.

The first time was when my parents' black Lab, Ed, contracted it nearly 10 years ago. My dad noticed, early in the morning on a weekday, that Ed had had diarrhea overnight and seemed listless. Everyone was in a rush to get off to school/work, so Dad instructed my sister to come home at lunch and check on him. If he was still acting funny, she was to take him to the vet. When she got home, maybe five hours later, Ed was already gone.

Ed was a 90-pound 2-year-old, and the vets were just baffled. Like the article above, they noted that HGE typically strikes smaller dogs, and they're not sure what causes it. Whatever it is, it was enough to bring down a large dog at the peak of health. My dad has never forgiven himself for not taking Ed to the vet that morning.

HGE reared its head again with my current dog, Daisy, about four years ago. I woke up one morning to the sound of Daisy pacing constantly. I got out of bed and saw she'd had diarrhea on the carpet - she'd never had an accident before.

I took her outside immediately and she stopped to go to the bathroom. It was pure blood. We ran to the emergency vet's office on the double and they were able to pump her full of fluids and antibiotics. She stayed overnight and was fine.

The scariest thing about HGE is its unknown cause. There's nothing specific you can do to prevent it. Very frightening.

Submitted by Shea Cox DVM | February 20 2012 |

Hi Kathleen~

I am so sorry to hear about Ed, and I can understand the continued guilt; I am wondering if what actually happened to him was something called a "mesenteric torsion," as that seems to fit more with what you have described (HGE alone would not cause death in that large of dog in such a short time). And if mesenteric torsion was the cause, the mortality rate is nearly 100%, meaning, nothing could have ever been done to save him, no matter how quickly your dad got him to the vet.

It generally happens in large breed dogs, and is another freakish thing in medicine. The intestine "twists" upon itself (like bloat/GDV, but with the intestines instead of the stomach), and this is generally followed by sudden diarrhea and rapid decline. In fact, we just had a case of this with El Cerrito's only police dog this past week... the officer noted some diarrhea in King and he rapidly appeared to get sick. It was literally only a short 37 minutes from the time he walked into our hospital to the time he was in surgery, and he still did not survive. It is a horrible, horrible, heart-breaking situation. I hope this offers your dad some small amount of peace.

And Daisy certainly sounds like your classic HGE... and I am so glad to hear she recovered with support! Yes, it is a very scary thing to observe, especially the very first time.

Thank you for sharing your experiences- I feel it truly helps others!

Submitted by Kathleen St John | February 23 2012 |

The mesenteric torsion thing is interesting. I don't know if the vets considered that. I do know that they did a necropsy and some testing of Ed's tissues, and that HGE was just their possible final diagnosis. Like, "Cause of death: HGE?"

I didn't mention it in the earlier post, but I think the amount of blood on the scene is what tipped it toward HGE. My dad thinks that Ed had been bleeding overnight, but he didn't see it in the grass in the early morning light. (Ed had a house in the yard that he slept in.) Sigh. Poor Ed. He was a very good dog.

But, yes, having encountered possible-HGE once, I was prepared when I saw the signs in Daisy years later. I'm sure most dog owners would be alarmed if their dog started expelling blood, but I was like, "Get the car. We're going to the vet RIGHT NOW." Think I was still in my PJs.

Submitted by Anonymous | March 14 2012 |

I had never thought diarrhea was a big deal until my dog was diagnosed with HGE. I almost lost her - a 75 lb young German Shepherd. I got back late from work and got her food ready. She refused to eat. Not a good sign! But I also noticed she was going outside a bit more than usual. I checked and noticed she had a touch of diarrhea -no blood. Okay, no biggie, she must have an upset tummy - I'll just watch her. As I got ready for bed, she went outside again, this time I noticed she didn't come back in. I went out to check on her and saw her standing looking out into space. I called to her - she did not respond. GAHHH. I ran to her and checked her gums. They were GREY! I freaked. I got her to the ER. They said if I hadn't gotten her in she would not have made it. The vet asked if there was any blood. I said no. Later the vet called me to tell me my dog was experiencing very bloody diarrhea. She said I must've caught it early. I am now very cautious when dogs experience diarrhea. It happened so fast, one moment she's running around, the next she's going into shock. So so scary!

Submitted by Shea Cox DVM | June 9 2012 |

Wow! That's quite an experience, and story! I am so glad to hear that it turned out well! I will never stop being amazed by the body and how quickly things can decline. I have to say, from my experience in the ER, most pet parents report that their pet "was just fine yesterday." It *is* so scary how quickly things can change. Thank you for sharing your comments~ hopefully this will help someone else who experiences this, as well! And good job watching your baby so closely!! :)

Submitted by Kim | February 23 2013 |

My Jack Russell Terrier is back at the vet now. He had a bout with what they said was HGE about 3 weeks ago. Took meds for a week and a half and was fine. Started again this morning with the same symptoms typical to HGE. He is 6 years old and this is the 6'th time to go through this. However they are getting too close together. Since June of this past summer, this is the 3'rd episode.
I watch his diet closely. No treats, no table food, and he has never been one to dig or eat things while doing his business in the back yard.
I've very worried and waiting now to find out if there is something more wrong with him. 3 Weeks ago, they also did x-rays to make sure there was no mass or obstruction and that was ruled out. Has anyone had repeated episodes of HGE?

Submitted by Heather | May 13 2013 |

My 2 year old mini schnauz/JRT had her 2nd bout in 6 weeks. She's had x-rays, complete blood work up, multiple other tests to rule out parasites, parvo, addisons, etc and everything seems normal so we get HGE by process of elimination. It's just so frustrating that we don't know what causes it and can't do anything to prevent it. And after a day of researching on the internet I am scared to death!

Submitted by Christina | May 22 2013 |

My staffordshire terrier is 2 years old. And within the past 8 months or so he has had several repeated episodes of HGE. We took him in the first three times and they kept him over night and treated him with fluids. He came home the next day, seemed to have gotten all better. But a month later it happened again. He has an episode every other week since the last time we took him in. I can't keep taking him to the vet its getting too expensive for me, especially this often. And they can't treat him for good, and hes just going to keep getting sick. I don't know what to do anymore. I keep him on a hypoallergenic diet, with absolutely no treats. Which seems to help a little bit, but i am also very worried

Submitted by Baby Dog Mama | July 6 2013 |

Wow! This sounds just like what my Lacey is going through. She has had repeated bouts of GI upset but only bloody diarrhea/vomiting this past time. However, it's getting closer and closer and closer. Just two months apart. Today she woke me up with foamy vomiting. I rested her tummy yesterday and that was the pay off. She is hungry, but I am watching her like a hawk waiting for the diarrhea to start. I don't know what to do. I have changed her food so many times (after each episode) and she's in the i/d formula now. I am an unemployed student so I have to get this under control soon. She is 11 and everyone thinks she is 2 -3 b/c she is so perky and lively (she is a westie). The last time we had just moved. She drank standing water in the shower, too, so it might have been that and/or stress, but it was bad and after a week on antibiotics, i asked them to extend them b/c she wasn't up to full Lacey power. So they did. Three days into the second course she woke up at 200% full Lacey power. I was sooo happy. But now she is starting to flag again.I hope I can wait until Monday to get her back to the vet and back on antibiotics/anti-emetics. I wish I could get her on something to reduce stress. Dr. Cox, any ideas???

Submitted by dolores dulaney | September 2 2013 |

Are you absolutely certain that there are no pesticides in or around your yard that he may be breathing in or getting on his paws and he likes it off. I would check your area and if you walk him check that area also. My baby died on Fri. the vet said it was HEG ..he was in so much pain and like a rag doll. When he started crying in pain even after 3 pain shots I could not stand it for him and had him go to sleep..My heart is so broken I don't know what to do. You can never be too careful they are like babies and can not tell you if they are ill ...He would have been 19 yo in Oct.

Submitted by Tia | March 21 2013 |

Two nights ago I came home to find our 8 month old german shephard pup was not on the porch like normal. We went out looking for him and found him about 100 ft from out porch looking scared as can be. He would come to us when we called for him just sat there looking at us. I carried him into the house so we could keep an eye on him. Yesterday I woke up to find that he had blood in his diarrhea. Scared I call the vet and asked what I should do. The vet said it sounded like parvo. I explained that there were 5 other dogs on the property and they were all fine. She said in that case not to worry and bring him in on Friday morning. He had diarrhea but no more blood. He would drink but not eat and we kept him inside to make sure we knew was was going in him and coming out. I had to call this morning and cancel the app. because at 3am my puppy died. It is driving me crazy not knowing what happened and if I should be worried about the other dogs even though they are not showing any signs of being sick.

Submitted by Marie Louise | March 24 2013 |

I'm so sorry to read about your lose. July our old standard poodle,her stomach twisted.

Submitted by Kate | July 28 2013 |

So sorry to hear about the loss of your puppy. Had your puppy had the necessary vaccines that ALL pups and dogs should have including those for parvo? Even if so, that doesn't afford complete protection in a pup that young I don't believe. Just know that if by chance it was parvo, parvo can live in the ground for like 7yrs I believe. Bad stuff. You have to be super diligent about bleaching anywhere your precious pup was. Hope your other dogs are ok & are up to date on vaccinations to prevent the parvo monster. Take care.

Submitted by Jan Yamauchi | July 14 2013 |

Our 4 year old mini schnauzer is going through this right now. It started with him vomiting at 9 pm and continued through thie night. During the night he started with the diarrhea. By morning his diarrhea was filled with bright red blood. We were camping and thank goodness we had cell phone service. I called the vet. Had the car packed and we flew down the mountain. We got to the vet and Tommie was very dehydrated. The vet ran the right tests. Started him on fluids and medications. After 2 days of fluids, medication,and prescription dog food, Tommie is on the road to recovery. Thanks to a wonderful, caring team at our vet hospital we still have our sweet boy to love. Tears come to my eyes thinking what could have happened.

Submitted by Sheridan | August 18 2013 |

My Mini Pomeranian is going through it right now :(. He weighs a total of 7.5lbs and started off with vomiting, no bloody poo or blood in his vommit until today. He has been in intensive care for the past 36hrs. He has had his fluids replaced along with glucose supplementation and his case is so severe that he has had to have a protein transplant as well as a plasma transplant.

My little boy is only 9 months old and I am not ready to say goodbye :(.
This is a scary illness it just comes on so suddenly, I am lucky he got to the Vet when he did or he wouldn't even have a slight chance at survival.

Submitted by gail schillinger | November 1 2013 |

my dog, Butch, just passed away. he was about 13 yrs. old Australian shepherd. it began with my dad, who is now deceased, coming to vistit Butch most every day and giving him a can of food and milkbone biscuits to an excessive amount and I pleaded with him to cut back--but he did not. Butch gained weight. My dad died and I began to reduce Butch's weight. I was successful, but he then also had an acl rip. The vet I was with told me he would be a 3-legged dog for life. I then sought chiropractor care for him and took him each month if not twice a month to get an adjustment. I had found Butch on the streets eating out of garbage cans and that is how he became mine. He never liked cats to which I have 5, I live in the country and all the wild cats outside through the years I had spade or neutered and now ONLY have the 5 inside ones that I made mine. Butch enjoyed outside more than inside even with the shaving of his fur each spring. He had a house with hay inside and packed around it--but was brought inside on cold nights and then each night with his aging, as well as on hot summer days. But we never bonded in many ways. He must of been abused for he feared the chain touching his bowl and when I first got him and put him on a chain outside, he fought it. Between being outside much of the time, his past, and me with my cats, plus Butch was so strong and I have neck and spine injuries that taking him for a walk only began as he aged and was not so strong for me. So at the chiropractor office, they would muzzle Butch for he hated control over his being, and at I would have to distract him. He developed another acl rip on the other leg. The vet had him on meds for 40weeks and he developed 2tumors and liver damage, and an ulcer. He was then on marin also. I took him off the metacam a year and a half ago for these problems came from too much of this medicine. His vet told me he would not be able to withstand the inflammation without this medicine. I chose to give it a try. Looking back, she never gave him dosages to increase it or decrease to which I would think should of been done to see what level he could get by with without harming other parts of his body.When I took him off all meds, marin and metacam, I was then giving him cod liver oil, standard processing whole body support, probiotics, cumin, silver, bio sprays of liver detox and constitutional enhanser, dasuquin with msm and a lot of water with half can of food and 2cups of dry. He improved and you would hardly know he had 2 aclrips. Also had a ramp for him to get in and out of the house. He had a gallon of water a day with his food mixture to which I think really helped him. I came home last week after visiting my daughter for two weeks and I had someone feeding my pets each day and making Butch his mixture with all the dry 'meds' I had conjured into making him healthy-my recipe. I bagged his food with these supplements for each day I would be gone. I don't believe he had the same amount of water given to him, but they did make the mixture minus the wet supplements. Oh yes, trumeel drops too, I gave him. The night I got home, I saw he had caught a possum and his hind legs were twisted. Last year when the ulcer was diagoised after also catching a possum, his legs were the same but returned as I nursed him back. Coming in at each night thereafter kept this from further happening. But I was gone and he was out each night tied to his doghouse. I did get his legs back last week, so I thought. His upper body strength was strong enough to pull me. But I was giving him anything he liked to eat to build him up along with my mixture of food.His treats contained gluosamine and on Saturday he had direehea with blood in it, but still was strong enough to go outside and lay down. I gave him chicken breasts and beef which he ate. But Saturday night he had the direehea again and on Sunday went outside and even took the short walk with me but did not drink the water nor did he eat anything. Monday he layed on the kitchen floor sleeping sound for Sunday night he had tried to stand and got in a position where his legs were not under him correctly. He also vomited yellow flem. I called his vet to which I have paid 5000-7000 the past two years with all of my pets being taken care of-----who told me that blood in the direehea is normal, and that the yellow flem is because his stomach is empty, and that the last time he was in, a month ago, he was so nervous that jus for me to give him one of the two pills left from last coating it with peanut butter or cheese and Pepcid ac. Butch slept sound most of Monday and would not take any of this from me. I also asked the vet if I brought him in, could we 'jumpstart' him with something. The vet kept saying he gets so nervous and avoided my bringing Butch in. the pill was tramadolbut I had no sucralfate left from last year which he was on both last year for the same problem. Butch deteriorated on Monday and on Tuesday I sought a vet to come and to put him to sleep or get me in to see if it was his time to be put to sleep. They kept constant contact with me-6calls that day, but it was too late, Butch was too weak. I had begun to feed him with a swringe--maybe I got it into his lungs--his gums were pink Tuesday morning but by noon, they were white---and our app. with this vet was for 4pm.they had nothing else for me-----at 3:10 Tuesday he died. He was coming along so good till the direehea. Was it the treats, was it the ulcer that was not attended to properly, was it the direehea that should of been addressed by his vet as well as the ulcer,was it his twisted body though he pawed at his bed to Sunday night to make it and took a walk with me and was so strong to pull me, was it food that caused the direehea to weaken him--his pillow he layed on I had just brought it up from the basement where I also had brought up my cat's pillow to which 3years ago I had exterminator the basement and maybe the poison was still on the pillows though the cats are ok----Butch had mats to lay on to give him footing, maybe the pillow threw him off so he could not get his footing as well though I wanted him to be comfortable and also had a sheet and towel on top of the pillow to lay on which were clean for him. I believe bloody direehea is abnormal though my vet told me otherwise as well as yellow vomit--and to not be so concerned as to not bring him in to be checked. They were uncomfortable with Butch to the point of muzzeling him---he was a hard dog at times then at other times, no problem. I wish I had called another vet Sunday or even Monday--but I had trusted my vet and had 'invested' in him to be there for Butch when the time called for it and he was not.

Submitted by Marvin Cecil Jr | January 6 2014 |

Thank you very much for your article. I now have closure. I just lost my 10 1/2yr old pit, 9:40pm. Over night! He vomited a little, twice, yesterday but no real ill effects, stool appeared to be solid. Some time last night he developed diarrhea with a large amount of blood in it. My little woman was at work and I am disabled with no vehicle. Unfortunately, by the time she got home, you could tell it wasn't long. He had passed enormous amounts of bloody/watery substances all day. I'll miss him so!
So, may God bless you for this article, and THANK-YOU!

Submitted by kunchok lhamo | June 1 2014 |

I lost my 1yr and few months old pomerian on16th feb 2014. His name was DORJE. When he was 6months he had his first attack of HGE. He had suddenly become inactive which was unnatural as he was so lively and active. We were concerned a bit but he did not otherwise have any visible signs of ailment. After a day of not eating,he had diarrhea and vomiting which were bloody in nature and had a pungent smell. He would throw up 4-5 times in a span of 2hrs and have diarrhea. It was late night,we could do nothing except wait for morning. Everytime prior to his throwing up we would witness contraction of his body preparing to hurl. We also noticed that his tail which is usually curled over his rear was since the morning tucked away between his legs. He did survive the 1st episode. However the 2nd time,we cud not detect the symptoms before it was too late. He again became inactive and did not eat for a whole day. There was no vomit or diarrhea. He ate little the next day but was moving around and looked normal. So we decided to wait for anotherday. The 3rd day he still had not shown any visible sign of sickness like vomit or diarrhea but he was eating less than normal. We took him to the vet the 4th day. Dorje had 102 degree fever. So they administered 3 injections: melonex for fever and 2 vitamins injections. They said it was probably a flu due to the change in the weather. Dorje came home and was looking to be doing good. But the 5th day-early Sunday morning he vomitted. The nature and the smell was too fimiliar to me but the vet had left the town and the clinic was closed. So even though I tried feeding glucose liquid he was too weak and died. I had deduced that Dorje must probably be a bit under the weather since he did not show signs of HGE. I hope to make people more aware by telling my story-my mistake and hope to save someone's pet. So if your dog becomes inactive and stops eating for more than a day,you need to take him immdiately to the vet. Later I found out that few people in the neighbourhood had also lost their beloved pets to HGE. It is very dangerous if not treated on time. I am also told that it is contagious because my new 4months old puppy also got sick after Dorje died. She has recovered much faster than Dorje since she is a mixed breed bigger than Dorje. I have always had dogs in the family and this is the 1st time we have ever had such an experience. I urge people to be very attentive to their pets.

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