12) diseases of oesophagus regurgitation vs vomitus Flashcards
1
Q
regurgitation general
A
Expulsion of material from the mouth, pharynx or oesophagus • Spontaneous • Passive backflow • Undigested food, no bile • Eating the regurgitated content (no nausea)
2
Q
regurgitation mechanism
A
• Altered motility • Obstruction of flow o External compression o Internal obstruction • inflammation
3
Q
vomitus general
A
Expulsion of material from the stomach and / or intestines
• Active muscle contractions, retching
• Undigested or digested food, gastric chyme, bile
• Nausea
4
Q
vomitus mechanism
A
- Activation of peripheral receptors within the gastrointestinal tract
- Activation of central vomit centre by CNS disease e.g. Motion sickness, neoplasia etc
- Vestibular disease
- Activation of chemoreceptor trigger zone by chemicals / toxins, e.g. uraemia, diabetic ketoacidosis
5
Q
Distinguishing regurgitation from vomiting
A
- History
• Nausea, retching, eating the content, bile, stretching or flexing the neck during swallowing, aspiration of water / liquid and coughing - Physical examination
• Palpation of distended cervical oesophagus, cervical mass, injury or foreign body - Thoracic radiography
• Obvious megaoesophagus, foreign body, perforation and pleuritis or PTX - Endoscopy: oesophagitis, hiatal hernia, stricture
- Fluoroscopy: motility disorders, hiatal hernia, stricture
6
Q
oesophagus - history and clinical signs
A
- Regurgitation
- Dysphagia
- Odynophagia (painful swallowing)
- Salivation
- Changes in appetite
• ↑ motility disorder
• ↓ inflammatory disorder - Aspiration pneumonia
• Coughing, fever, dyspnoea, pulmonary crackles - Cachexia, weight loss
7
Q
diagnostic evaluation of esophagus
A
- Physical evaluation
• Expanded oesophagus, pneumonia, neurological deficits (mydriasis), salivary gland, foreign body, mediastinal tumour - Laboratory examination
• WBC (pneumonia, perforation, pleuritis)
• Na+/K+ (hypoadrenocorticism → megaoesophagus)
• CK, AST (polymyositis → megaoesophagus)
• Acetylcoline receptor antibody (25% of acquired megaoesophagus: myasthenia gravis!)
• Coprology (spirocercosis) - Radiography
• Foreign body, PRAA, megaoesophagus - Endoscopy, fluoroscopy
8
Q
oesophageal diseases - oesophagitis
A
- Causes
• GOR, anaesthesia, persistent vomiting, foreign body, doxycycline (cats), motility disorder, megaoesophagus, caustic substances - Symptoms
• Odynophagia, regurgitation, salivation, food refusal, coughing, fever, dyspnoea - Diagnosis
• Clinical signs
• WBC ↑
• Endoscopy
• Radiography? - Treatment
• Omeprazole + prokinetics (see GOR treatment)
• Sucralfate suspension
• Total parenteral nutrition / enteral nutrition (in severe cases)
• Aspiration pneumonia: antibiotics - Prognosis usually good
• Untreated: stricture, megaoesophagus (cause or consequence?)
9
Q
gastro-esophageal reflux
A
- Poor closure of cardia → HCl, pepsin, trypsin, bile, HCO3- → inflammation; frequent problem!
- Aetiology
• Delayed gastric emptying
• Upper airway obstruction
• Hiatal hernia
• Anaesthesia
• Chronic vomiting - Symptoms
• Same as for oesophagitis
• Reverse sneezing
• Chronic bronchitis, laryngitis, rhinitis
• Eructation - Diagnosis
• Symptoms + history
• Endoscopy! (oesophagitis, hiatal hernia) - Treatment
• Low fat diet, avoiding late night feeding
• H2-receptor blockers/proton-pump inhibitors
• Prokinetics: cisapride, tegaserod (serotonin-4-receptor agonists)
• Sucralfate
• Enhance cardia closure
➢ Metoclopramide
➢ Erythromycin
➢ GABA “B” type agonist: baclofen
• Brachycephaly syndrome → surgery - Prognosis usually good
10
Q
Oesophageal foreign body
A
- Symptoms • Regurgitation • Salivation • Distended abdomen • Coughing, fever, dyspnoea - Diagnosis • Symptoms • WBC ↑ • Thoracic radiography (survey and contrast) or • Endoscopy - Treatment • Endoscopic removal ➢ Informing the owner (risk of procedure: perforation, PTX, surgery) ➢ Prepared operation room ➢ Anaesthesiologic preparedness • Unsuccessful attempt (30 – 70%) ➢ Surgery ➢ Gastric tubing ➢ Euthanasia
11
Q
oesophageal motility disorders
A
- Dysmotility / oesophageal weakness
• Motility disorder + food retention + regurgitation
• Aetiology: idiopathic, muscle atrophy, myasthenia gravis, autoimmune disorders, post-anaesthetic condition (reversible), oesophagitis
• Types
➢ Megaoesophagus
o Severe dysmotility + oesophageal expansion
➢ Partial oesophageal dysmotility
➢ Dysautonomia
➢ Diverticulum
• Clinical manifestation
➢ Dysphagia / regurgitation
➢ Dysphagia / regurgitation + bronchopneumonia
➢ Bronchitis / bronchopneumonia → dysmotility
• Symptoms
➢ Regurgitation, salivation, coughing, fever, dyspnoea, weight loss
• Diagnosis
➢ Fluoroscopy
➢ Radiography (survey, contrast
12
Q
Megaoesophagus
A
- Common in dogs, rare in cats
- Persistent reduced motility of the oesophagus
- Laryngeal paralysis can lead to megaoesophagus
- Must assess for aspiration pneumonia
- Congenital (cause is unknown)
• Miniature Schnauzers, Great Danes, Dalmatians, Shar-Pei, Irish Setter, Labrador Retriever
• Clinical signs usually develop when weaning onto solid food
• No treatment
• Poor prognosis - Acquired (adult onset)
• Primary
➢ Idiopathic
➢ Diagnosis of exclusion (i.e. causes of secondary)
➢ Typically, large breed dogs
➢ Treatment
o Special feeding
▪ “Bailey chair” – keeping the patient vertical while feeding
o Bethanechol + Sucralfate
• Secondary
➢ Myasthenia gravis (20% of cases)
o Immune response against acetylcholine receptors
o +/- can be focal or generalized (systemic weakness)
o Treatment: pyridostigmine
➢ Other
o Hypoadrenocorticism (prednisolone), lead poisoning (Ca-EDTA), oesophagitis, hypothyroidism (levothyroxine), systemic lupus erythematosus (prednisolone), polymyositis/polymyopathy (see SLE)
13
Q
Spirocercosis
A
- Spirocercosis lupi • Widely distributed nematode, causing parasitic nodules in the oesophagus, aortic aneurysms, spondylitis - Symptoms • Regurgitation, vomiting, weight loss, coughing, dyspnoea, rarely sudden death - Diagnosis • Faecal examination • Endoscopy - Treatment • Doramectin ➢ Off-label ➢ MDR1 gene mutation! • Imidacloprid/moxidectin • Surgery - Prevention • Parasitic prevention with milbemycin
14
Q
Persistent right aortic arch
A
- Congenital disease
- Extraluminal compression by the ligamentum arteriosum
- Symptoms
• Shortly after the animal eats solid food for the first time
• Regurgitation, coughing, dyspnoea, weight loss
• Rarely minor signs, patients are several years old - Diagnosis
• Survey and contrast radiography
➢ Ventral and leftward tracheal deviation, cranial oesophageal dilatation
• Endoscopy - Treatment
• Surgery