Symptomatic Management of Primary Acute Gastroenteritis€¦ · causes of acute gastrointestinal...
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Table 1. Selected Causes of Secondary Acute GastroenteritisAlgal • Prototheca species
Bacterial •Campylobacter species •Clostridia species•Escherichia coli •Neorickettsia helminthoeca • Salmonella species
Drugs •Antibiotics•Cyclosporine •Glucocorticoids•Mycophenolate •Nonsteroidal anti-inflammatory drugs
Parasitic •Ancylostoma caninum •Ollulanus tricuspis• Physaloptera species• Strongyloides species• Toxoascaris leonina• Toxocara canis
Protozoal •Cryptosporidium parvum •Giardia species• Isospora canis
Systemic disease
•Bacterial cholecystitis •Gallbladder mucocele •Gastric dilatation and volvulus •Hepatic disease •Hypoadrenocorticism • Pancreatitis • Pyometra •Renal disease• Sepsis • Septic peritonitis• Splenic torsion
Toxins •Chocolate• Lead•Mushrooms•Organophosphates•Xylitol• Zinc
Viral •Canine coronavirus •Canine parvovirus• Feline immunodeficiency virus• Feline leukemia virus• Feline parvovirus (panleucopenia virus)
Acutegastroenteritisisatermusedtodescribeasyndromecharacterizedbythesuddenonsetofvomitingand/ordiarrheacausedbygastrointestinalmucosalinflammation.Thisdiagnosisisseldomconfirmedby
histopathologicevaluation;instead,itisbasedonaconsistentclinicalpresentationandexclusionofotherpotentialcausesforthepatient’sclinicalsigns.Mucosalinflammationisassumed,butnotproventobepresent.Therefore,acute gastroenteropathyisperhapsamoreappropriatename.
DIAGNOSTIC EVALUATIONAcutegastroenteritisisamongmanypotentialcausesofacutevomitinganddiarrhea(Table 1).However,inmanycases,thecauseofprimaryacutegastroenteritisisnotdetermined.Rapidresolutionofclinicalsignsoftenmeansthatextensivediagnosticevaluationisunnecessary.Physical ExaminationNospecificphysicalexaminationfindingsarepathognomonicforacutegastroenteritis,andsomedogsdonothaveanysignificantabnormalities.Findingsconsistentwithacutegastroenteritisincludelethargy,pytalism,andabdominaldiscomfort.Itisparticularlyimportanttoassessthepatient’s
hydrationstatusandpalpatetheabdomencarefully,checkingforphysicalexaminationfindingsthatwouldwarrantfurtherdiagnosticevaluation(ie,abnormalitiesthatsuggesttheproblemismoresignificantthanstraightforwardacutegastroenteritis)(Table 2).Findingsthatindicatedehydrationincludedryoralmucousmembranes,prolongedcapillaryrefilltime,andprolongedskintent.Tachycardia,weakpulses,andcoolextremitiesareconsistentwithhypovolemia.
Laboratory AnalysisPatientswithanormalphysicalexaminationand
Symptomatic Management of Primary Acute GastroenteritisYuri 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
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mildclinicalsignsmaynotrequirelaboratorytestingoninitialpresentation.However,laboratorytestingmaybeindicatedtoruleoutextra-gastrointestinalcausesofacutegastrointestinalsigns,suchasacutekidneyinjury,acutehepatitis,andpancreatitis,andmetaboliccomplicationsofacutegastroenteritis,suchaselectrolyteandacidbaseabnormalities.Whenperformed,laboratorytestingshould
includeacompletebloodcount,serumbiochemicalprofile,andurinalysis.Measurementofserumcaninepancreas-specificlipaseconcentrationmayalsobeindicatedtodiagnosepancreatitis,andbaselineserumcortisolconcentrationmaybemeasuredinordertoexcludehypoadrenocorticism.Additionallaboratorytestingforinfectiousdisease
shouldbeconsideredbasedongeographiclocationandsignalment.Forexample,serologyassistsindiagnosisofSalmonpoisoningdiseaseinthePacificNorthwest.Indogswithdiarrhea,fecalflotationanddirectsmearexaminationshouldbeperformedtoscreenforprimaryorconcurrentparasitism(Figure 1).Inpatientswithclinicalfindings(Table 2)or
laboratoryresultsthatsuggestaseriousunderlyingcause,orthosethatdonotrespondtotherapy,furtherdiagnosticevaluationisindicated.Earlyidentificationisespeciallyimportantinpatientsrequiringsurgicalintervention,suchasthosewithanobstructiveintestinalforeignbody(Figure 2).
ImagingAbdominalultrasonographyand/orabdominalradiographyarestronglyadvisedinpatientspresentingwithabdominalpaintoscreenfordiseasesrequiringsurgicalintervention.Itisimportantto
rememberthatpancreas-specificlipaseconcentrationscanbeincreasedindogsandcatswithgastrointestinalforeignbodies.Therefore,itisessentialtoruleoutgastrointestinalforeignbodieswithabdominalradiographsand,possibly,abdominalultrasoundbeforepancreatitisisdiagnosed.Ifthereishighsuspicionforagastrointestinalforeignbodythatmayhavebeenobscuredbyfluidorgas,diagnosticimagingshouldberepeated.
THERAPEUTIC APPROACHWhenacutegastroenteritisistheprimarycauseofvomitingand/ordiarrhea,thesymptomatictreatmentsdiscussedinthisarticleareappropriatefortherapy.However,ifgastroenteritisoccurs
FIGURE 1. Gastric nematode presumed to be Physaloptera rara visualized during gastroscopy. The hemorrhage observed is associated with gastric biopsy.
Table 2. Selected Clinical Findings That Indicate Further Diagnostic Evaluation in Dogs & Cats with Acute Vomiting and/or Diarrhea •Abdominal pain•Anorexia•Bradycardia•Chronic vomiting or diarrhea•Hematemesis•Hyperthermia or fever• Jaundice• Lack of current vaccinations• Lymphadenopathy•Masses or organomegaly on abdominal palpation•Melena • Polyuria/polydipsia• Tachycardia• Tachypnea, cough, or abnormal lung sounds•Weak pulses•Weakness•Weight loss
learn MoreTurn to page 77 to read the article,Endoscopic Foreign Body Retrieval.
FIGURE 2. Fabric gastric foreign body visualized during gastroscopy.
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secondarytoanunderlyingdisease,suchashypoadrenocorticism,itisessentialtotreattheprimaryconditioninadditiontoprovidingsymptomaticandsupportivetherapy.Thisarticleemphasizessymptomatictreatmentof
primaryacutegastroenteritisratherthandetailingspecifictreatmentofseriousunderlyingdiseasesthatmaycausesimilarclinicalsigns.
ANTIEMETIC DRUGSForacutegastroenteritis,antiemetictherapyisoftenusedfortheinitial24to48hourswhenvomitingisaprominentclinicalsign(Table 3).Benefitsinclude:• Improvedpatientcomfort•Decreasedongoingfluidandelectrolytelosses• Earlierreintroductionofenteralnutrition•Reducedriskofesophagitisandesophagealstrictureformation.Takecarenottomaskongoingdiseasewith
prolonged(ie,greaterthan3days)antiemetictherapy.Inaddition,toreducetheriskofgastrointestinalperforationandavoiddelayofsurgicalinterventionbymaskingclinicalsignsofintestinalobstruction,donotadministerantiemeticorprokineticdrugtherapywhenaforeignbodyissuspectedorconfirmed.Severalclassesofantiemeticdrugsareusedinsmall
animalmedicine.Occasionally,refractorycasesrequiretheuseofmorethanoneofthesedrugsatthesametime.
Ondansetron & DolasetronOndansetronanddolasetronareserotonin(5-HT3)antagonistswithpotentantiemeticactivitythatarecommonlyusedoff-labeltocontrolnauseaindogsandcats.Thisclassofdrugblocksthechemoreceptortriggerzoneandvagalafferentpathwaysinvolvedinemesis.Inourexperience,thesedrugsareveryeffectiveforcontrolofvomitingindogsandcats.
MaropitantSubstancePisaneurotransmitterthatbindstoneurokinin-1(NK-1)receptorsandcanresultinvomiting.Therefore,NK-1receptorantagonistsarepowerfulantiemeticseffectiveattreatingbothperipheralandcentralcausesofvomiting.Maropitant,aNK-1receptorantagonist,is
currentlytheonlylicensedantiemeticforuseindogsandcatsand,inouropinion,isveryeffective.Thisdrugmayalsohaveananalgesiceffectand,thus,iswidelyusedinpatientswithvomitingandabdominalpain,suchasthosewithpancreatitis.1Theefficacyofmaropitantforthecontrolofpresumednauseaiscontroversialassomestudieshaveshownabenefitwhileothershavenotdocumentedabenefit.2-6
WhilemaropitantisnotlicensedforIVuse,weandotherclinicianshaveadministereditbythisroute—atadoseof1mg/kgQ24H—withoutapparentadverseeffects.Themanufacturerrecommendsthatafter5daysofcontinuous
Table 3. Medical Therapy for Vomiting Due to Acute GastroenteritisDRUG DOGS CATS
AntiemeticsOndansetron 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 H2 mg/kg PO Q 24 H1 mg/kg IV Q 24 Ha
1 mg/kg SC Q 24 H2 mg/kg PO Q 24 H1 mg/kg IV Q 24 Ha
Metoclopramide 0.2 mg/kg SC or PO Q 8 H1–2 mg/kg/H IV CRI
0.2–0.4 mg/kg PO or SC Q 6–8 H1–2 mg/kg/H IV CRI
GastroprotectantsSucralfate 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 administrationb. Potential reduced risk of emesis if administered as a slurry
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administrationthedrugshouldbediscontinuedfor24hourstoavoiddrugaccumulation;thentreatmentcanberestarted,ifnecessary.
MetoclopramideAntidopaminergicagents,suchasmetoclopramide,havebothcentralandperipheralantiemeticeffectsandareusedoff-labelindogsandcats.Metoclopramidealsostimulatesthereleaseofacetylcholinefrompostganglionicnervesintheperipheralnervoussystem,whichleadstoincreasedgastriccontractionsandincreasedgastroesophagealsphinctertone.Thispromotilityeffectmayalsocontributetoitsantiemeticproperties.Metoclopramidecancauseneurologicsideeffects,
includingexcitementandrestlessness.Theshorthalf-lifeofthisdrugnecessitatesfrequentdosing.Inourexperience,itismosteffectivewhendeliveredviaanIVconstantrateinfusionbutisnotaseffectiveasmaropitant,ondansetron,ordolasetron.Metoclopramidemaynothaveadirectcentralantiemeticeffectandisalesseffectiveantiemeticagentincatsthanindogs.7Forthisreason,weseldomuseitforthispurposeintheformerunlessaprokineticagentisalsoindicated.
PhenothiazinesPhenothiazines,suchaschlorpromazineandprochlorperazine,arepotentcentrallyactingantidopaminergicsthatinhibitthevomitingcenterandchemoreceptortriggerzone.Thisclassofdrugalsohasantihistaminergicandanticholinergicproperties.8Theyarenotrecommendedinhypovolemic
patientsduetopotentialforhypotension,andthesedrugsarenotlicensedforuseindogsandcats.Phenothiazinescancausemildsedationandarenolongercommonlyusedduetotheavailabilityofothereffectiveantiemeticdrugs.
GASTROPROTECTANTSSucralfateSucralfateisasulfateddisaccharidethatbindstotheacidicmoietiesofexposedcollagenindamagedmucosa,creatingaprotectivebarrieragainstfurtheraciddamage.Italsostimulatesprostaglandinreleaseandcellularproliferationatsitesofulcerationandincreasesmucusproductionandbicarbonatesecretion.Sucralfateisrecommendedonlyincasesofsuspected
gastrointestinalerosionorulceration,suchasthosethatpresentwithhematemesisormelena.Itcaninterferewithabsorptionofotherdrugs,andistypicallygivenatleast2hoursbeforeorafterothermedications.
Famotidine & RanitidineFamotidineandranitidinearehistamine-2(H2)-receptorantagoniststhatcompetitivelyinhibithistamine-inducedacidsecretionbythegastricparietalcells.Famotidineismoreeffectiveatincreasing
caninegastricpHcomparedwithranitidine,butranitidinealsohasanticholinesteraseactivity.ThisactivitymayresultinsomeprokineticactionbutinstudieswasonlyaseffectiveasasalineplaceboatincreasinggastricpHindogsandcats;thus,itisnotrecommendedforitsacid-suppressingeffects.9,10
H2-receptorantagonistsarelessefficaciousthanprotonpumpinhibitors(PPIs)in vivo,butthedegreeofgastricacidinhibitionnecessaryfortherapeuticeffectisunknown.H2-receptorantagonistsmayalsohavecytoprotectiveproperties.11,12
Omeprazole & PantoprazoleOmeprazoleandpantoprazolearePPIsthatirreversiblyinhibitacidproductionbygastricparietalcells.ThisclassofdrugismoreefficaciousandhasalongerdurationofactivitythanH2-receptorantagonists;itmayalsoexertacytoprotectiveeffectbyenhancingprostaglandinsynthesis.9-11,13
Indogsandcats,twice-dailydosingofomeprazoleismoreeffectiveatreducinggastricacidsecretionthanonce-dailyadministration.9,10Coadministrationoffamotidineandpantoprazoledoesnotseemtobeanymoreeffectivethantherapywithpantoprazolealoneand,thus,thereisnobenefitinusingaH2-receptorantagonistforthefirst24hoursoftherapy.14
Becauseofthis,PPIsarethepreferredtreatmentfordogsandcatsknownorsuspectedtohaveesophagealorgastroduodenalulceration.11,14Anecdotally,somedogsandcatswithacute
gastroenteritis,butnootherfindingsthatindicategastroduodenalulceration,suchashematemesisormelena,appeartorespondfavorablytoacid-suppressingdrugs.However,useofthesedrugshasnotprovenbeneficialinanystudiesindogsandcatswithuncomplicatedgastroenteritis;thus,theyarenotroutinelyrecommendedforbriefepisodes.Inhumans,long-termuseofPPIshasbeen
associatedwithsuchsideeffectsascobalamindeficiency,irondeficiency,hypomagnesemia,increasedsusceptibilitytopneumonia,entericinfections,fractures,hypergastrinemia,andcancer.15Toourknowledge,otherthanhypergastrinemia,thesideeffectsdescribedabovehavenotbeenreportedindogsandcatsreceivinglong-termtreatmentwithPPIs.
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MisoprostolMisoprostolisasyntheticprostaglandinE1thatactsonparietalcellstoinhibitsecretionofgastricacid.Additionally,ithasacytoprotectiveeffectbyincreasingsecretionofmucusbygastricgobletcells,increasinggastricmucosalbloodflowandincreasingturnoverofgastricmucosalcells.PPIsandH2-receptorantagonistsarethoughtto
bemoreeffectivefortreatmentofgastrointestinalulcers,andmisoprostolmaycausevomiting,diarrhea,andabdominalpain.Useofmisoprostolis,therefore,notadvisedindogswithacutegastroenteritisunlessgastroduodenalulcerationassociatedwithnonsteroidalanti-inflammatorydrug(NSAID)useisthoughttobethecause.
ANTIDIARRHEAL THERAPYMostcasesofuncomplicatedacutegastroenteritisthatpresentwitheithersmallorlargeboweldiarrhearesolvewithouttherapeuticintervention.Casesthatpresentwithdiarrheashouldhaveafecalexaminationandconsiderempiricaldewormingwithabroadspectrumanthelminthic.However,thereareafewoptionsforsymptomatictreatmentofdiarrhea.
LoperamideLoperamide,anopioidantimotilitydrug,hasbeenusedoff-labelindogswithdiarrhea.Itdecreasesintestinalmotilityandreducesmucosalsecretions.DosesusedtotreatdiarrheacancauseneurologictoxicityindogswiththeABCB1(formerlyMDR1)mutation;therefore,avoidthisdruginalldogscarryingthisalleleandat-riskdogbreeds(ie,Australianshepherd,Shetlandsheepdog,long-hairedwhippet,collie,Englishshepherd,Germanshepherd)thathaveanunknownstatus.Wedonotrecommenduseofthisdrugfortreatingdogsorcatswithacutegastroenteritisduetothispotentialtoxicityandbecausethediarrheaassociatedwithgastroenteritisisusuallyself-limiting.
ProbioticsProbioticsarelivemicroorganismsthatconferahealthbenefitonthehost.16Thesehealtheffectsareexertedbydirectinhibitionofcolonizationbypathogenicmicroorganisms,orbyimmune-enhancingeffectsongut-associatedlymphoidtissue.17-19Probiotics(Table 4)aresometimesusedtotreat
dogsandcatswithacutediarrhea.Eachprobiotichasadifferentformulationofbacteria,anditisunknownwhich,ifany,aremostusefulfortreatmentofacutegastroenteritiswithresultantdiarrhea.Therefore,
furtherstudyoftheseproductsisneededbeforedefinitiverecommendationscanbemade.Theefficacyofsomeprobioticsfortreatmentof
chronicdiarrheaindogsandcatshasbeenevaluatedbut,toourknowledge,therehaveonlybeen2studiesevaluatingtheefficacyofprobioticsindogswithacutediarrhea;bothfoundthatprobioticsdecreasedthedurationofdiarrheaindogswithacuteidiopathicdiarrhea.20-23
Whenselectingaprobiotic,itisimportanttochooseaproductthathasbeensubjectedtoadequatequalitycontrolduringthemanufacturingprocess,suchastheoneslistedinTable 4.
Antimicrobial TherapyAntimicrobialtherapywithmetronidazoleortylosinissometimesusedempiricallyindogsandcatswithidiopathicacutegastroenteritisthatpresentwitheithersmallorlargeboweldiarrhea.Bothantibioticsareusedtopotentiallytreatspecificbacteriathatmaycauseacutegastroenteritis(eg,Clostridium perfringens).However,astudyevaluatingtheefficacyof
amoxicillin/clavulanicacidindogswithacutehemorrhagicdiarrheasyndrome(formerlycalledhemorrhagicgastroenteritis)demonstratednobenefitintreateddogsversuscontroldogs.24Therefore,routineantibiotictherapy(includingtheuseofmetronidazole)isnotrecommendedindogsorcatswithacutegastroenteritis.Antibiotictherapymayhavearoleindogsandcats
suspectedtohavebacterialtranslocationthroughadamagedgastrointestinalmucosalbarrier,andthisispotentiallymorelikelyincasesofgastrointestinalbleeding.However,wereserveantimicrobialtherapyforpatientswith:•Moredefinitiveevidenceoftranslocation,suchasleukocytosis,elevatedimmaturewhitebloodcellcount,andpyrexia
• Leukopeniaorthosethatareimmunosuppressed•Aspecificbacterialenteropathogen(eg,campylobacteriosis)
•Chronicdiarrhea(asatherapeutictrialtoruleoutdysbiosis).
Table 4. Examples of Commercial Probiotics for Dogs & Cats • FortiFlora (purina.com)• Prostora (iams.com)• Proviable (nutramaxlabs.com)• Sivoy (sivoy.net)
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NUTRITIONAL MANAGEMENT FastingTheconceptofcompletefastinghasbeenquestionedinrecentyearsfordogswithacutegastroenteritis.Completerestrictionoffoodmaybereasonableforashortperiod,butanearlyreturntoappropriateoralintakeisadvisedunlesscontraindicated,suchasincasessuspectedtohaveforeignbodies.
Diet ConsiderationsAwidevarietyofcommerciallyavailabledietsismarketedfordogsandcatswithgastroenteritis.Eachisformulatedwithslightlydifferentproteinandcarbohydratesourcesandfatcontent;somecontainotherpotentiallybeneficialconstituents,suchasfructooligosaccharidesoromega-3fattyacids.Catsshouldreceiveenteralnutritionassoonas
possibletoavoidproteincaloriemalnutrition,whichcanleadtofelinehepaticlipidosis.Acommerciallyavailable,highlydigestibledietisrecommended.Thegoaloffeedingahighlydigestibledietistoreducetheriskformalabsorption.
Dietary FiberForpatientswithlargeboweldiarrhea,dietaryfiberisanimportantcomponentofdietarymanagement.Whiletheoptimalamountandtypeofdietaryfiberfortreatmentofdogsandcatswithacutegastroenteritisarenotknown,thereisgeneralagreementthat,indogsandcats:•Dietaryfermentable fiberenhancesnormalcolonicfunctionbyprovidingafuelsourceforcolonocytes
•Dietarynonfermentable fiberincreasesfecalbulk,whichpromotesnormalizedcolonicmotorfunctionanddefecation.Potentialsourcesincludecannedpumpkin,brown
rice,peas,andcarrots.Therearenoestablishedguidelinesforfibersupplementationincasesofsmallboweldiarrhea.Inonestudy,dogswithcolitisthatreceived
addeddietaryfiberexperiencedsignificantclinicalimprovementcomparedwithdogsfeddietswithoutaddedfiber.25
FLUID THERAPYAcutegastroenteritiscanleadtofluidlossesandelectrolyteimbalancesthatnecessitatefluidtherapy.
Subcutaneous TherapySCfluidtherapymaybeappropriateformilddehydrationorwhenoutpatienttherapyiselectedduetofinancialconcerns;however,itwouldbeconsideredinappropriateforsignificantdehydrationorhypovolemia.SCfluidsshouldnotbesupplementedwithdextrosebecausebacterialcontaminationandcellulitiscandevelop.WheresupplementationwithdextroseisneededIVadministrationispreferable.
Oral TherapyOralelectrolytesolutionscanbeusedincasesofmilddehydration.Inarecentstudy,thisrouteofadministrationwassafeandeffectiveindogswithhemorrhagicdiarrhea.26
Intravenous TherapyGoal-directed,targetedIVfluidtherapytocorrectanestimatedpercentdehydrationoveraspecifictimeframeandtoachievenormovolemiaisrecommendedformoderatetoseveredehydrationorhypovolemia.Balancedreplacementcrystalloidsolutions,suchaslactatedRinger’ssolution,areanappropriatechoiceinmostpatients.Ongoingmonitoringofserumelectrolyteconcentrationsisrecommendedbecausesupplementationissometimesrequired.
H2=histamine-2;NK-1=neurokinin-1;NSAID=nonsteroidalanti-inflammatorydrug;PPI=protonpumpinhibitor
YURI LAWRENCEYuri 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 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.
Inonestudy,dogswithcolitisthatreceived
Yuri Lawrence, DVM, MA, MS, Diplomate
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