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Y4 SA - Abdominal & rectal disease > Anorexia & weight loss > Flashcards

Anorexia & weight loss Flashcards

1
Q

What do we mean by weight loss?

A
  • reduction in total body fat / muscle
  • body condition rather than weight as other things can affect weight e.g. ascites, dehydration, masses
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2
Q

Why does weight loss occur?

A
  • occurs when energy expenditure / calorie loss exceeds intake
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3
Q

3 broad causes of weight loss

A

Malnutrition
- insufficient calories ingested to maintain body condition

Maldigestion/malabsorption
- sufficient calories ingested by not being absorbed properly

Malutilisation
- sufficient calories ingested and absorbed but not used in the right way

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4
Q

Weight loss due to malnutrition - causes

A
  • diet
  • don’t want to eat
  • physically can’t eat
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5
Q

Weight loss due to malnutrition - diet

A

Inappropriate e.g.
- puppy vs adult diet
- normal vs prescription
- neutered and weight loss diets

Not enough
- consider size, age, activity level, etc
- amount to feed varies between diets (product specific feeding charts as a guide)
- don’t forget about changes such as pregnancy and lactation: need to alter feed accordingly

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6
Q

Weight loss due to malnutrition - don’t want to eat

A

Pain
- when eating, e.g. dental/oral/pharyngeal/ortho
- elsewhere

Stress
- common in cats
- bullying/competition for food
- stressful environment (e.g. hospital)

Nausea
- caused by visceral, vestibular and/or chemoreceptor trigger zone stimulus
- many systemic dz’s

Pyrexia
- many inflammatory/infectious conditions
- common cause of inappetence in cats

Other causes of appetite suppression

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7
Q

Causes of increased & decreased appetite

A

Increased
- empty stomach releases hormone Ghrelin
- sensory signals (smell, texture, temp, taste)
- behavioural cues
- environmental signals
- medications (e.g corticosteroids, phenobarbitone)
- hypoglycaemia
- lots more

Decreased
- satiety hormones from intestines if food
- gastric distension
- leptin from adipocytes
- insulin
- inflammatory cytokines
- pyrexia/hyperthermia
- toxins e.g. uraemia
- chronic pain
- stress
- nausea
- lots more

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8
Q

Weight loss due to malnutrition - physically can’t eat (common causes)

A
  • dental dz
  • oral/pharyngeal/oesophageal masses
  • mandibular/maxillary abnormalities e.g. craniomandibular osteopathy
  • congenital abnormalities e.g. cleft palate, persistent right aortic arch
  • neuromuscular disorders
    – generalised e.g. tetanus or botulism
    – localised e.g. masticatory muscle myositis, cricopharyngeal achalasia
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9
Q

Masticatory muscle myositis - cause / what is it?

A
  • immune mediated inflammatory condition
  • inciting cause unknown
  • autoantibodies against type 2 muscle fibres
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10
Q

Masticatory muscle myositis - presentation

A

Acute phase
- can be missed by O
- inflamed masticatory muscles
- hard to open jaw as painful

Chronic phase
- fibrosis & atrophy -> can’t open mouth (differentiates from trigeminal neuritis)
- no pain but anorexia & weight loss

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11
Q

Masticatory muscle myositis - diagnosis

A

Haematology
- eosiophilia

Biochem
- increased globulins and creatine kinase

Electromyography (EMG)
- spontaneous electrical activity

Biopsy histology
- lymphocytic-plasmacytic cellular infiltrates, muscle atrophy & fibrosis

Bloods
- circulating autoantibodies against type 2M fibres

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12
Q

Masticatory muscle myositis - tx

A
  • best chance of success in acute phase
  • immunosuppressive therapy (preds 2mg/kg)
  • dose gradually tapered over months
  • chronic: attempt to stretch jaw open under GA?
  • recurrence common
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13
Q

Cricopharyngeal atelectasis - what is it a differential for?

A
  • dysphagia
  • regurgitation
  • can cause secondary aspiration pneumonia
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14
Q

Cricopharyngeal atelectasis - breed most commonly affected

A
  • springer / cocker spaineils
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15
Q

Cricopharyngeal atelectasis - what is it?

A
  • neuromuscular motility disorder causing incomplete/asynchronous relaxation of the upper oesophageal sphincter
  • means when the animal swallows food gets stuck in the lower pharynx/upper oesophagus
  • usually congenital, rarely acquired
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16
Q

Cricopharyngeal atelectasis - diagnosis

A

Fluoroscopy
- cricopharyngeal muscle doesn’t relax
- retention of barium in the caudal pharynx

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17
Q

Cricopharyngeal atelectasis - tx

A

Surgery
- cricopharyngeal myotome or cricopharyngeal and thyropharyngeal myectomy
- 65% success (less if acquired

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18
Q

Weight loss due to malnutrition - protocol

A

Full hx including
- diet: what, how much, how often?
- where/with who do they eat (stress?)
- changes at home (stress?)
- how do they eat / try to eat? (video?)
- activity levels / life stage (anticipated calorie consumption)
- signs of nausea or pain? drooling, pawing at mouth

Thorough CE, including:
- full exam for possible causes of nausea or pain
- thorough exam of mouth/jaw/head/neck & ortho exam
- able to open mouth fully & without pain?
- offer treats in consult from usual feeding heigh: observe prehension, mastication and swallow
- remember to check temp

Diagnostic test (depending on hx/CE):
- haem/biochem/urinalysis: systemic dz
- radiographs
- fluoroscopy: barium swallow
- EMG
- muscle biopsy

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19
Q

Weight loss due to maldigestion/malabsorption - what is it almost always associated with?

A
  • signs of GI signs
  • presenting GI signs can be similar to some malutilisation causes
  • appetite often increased (if not associated with nausea)
20
Q

Causes of maldigestion (stomach)

A
  • v+/regurgitation
  • common categories
    – neoplastic (e.g. gastric adenocarcinoma)
  • inflammatory (e.g. gastritis, gastric ulceration)
  • infectious (bacterial, viral, protozoal, endoparasites)
  • obstructions (e.g. FB / strictures)
  • congenital/traumatic (e.g. hiatal hernia)
21
Q

Causes of malabsorption (SI/pancreas)

A
  • reduced absorption of fats/proteins/carbs
  • d+ or increased volume of faeces
  • changes in colour/consistency
  • can also be associated with v+

Causes can be considered by location within intestines
- luminal (e.g. EPI, dysbiosis)
- mucosal (infectious or inflammatory enteropathies, villous atrophy, neoplasia)
- post mucosal (e.g. lymphangiectasia, vasculitis, portal hypertension)

Some common systemic dz can cause GI signs which can be severe enough to cause malabsorption/malidgestion without pathology of the GIT. Common examples include:
- hyperthyroidism in cats
- hypoadrenocorticism in dogs

22
Q

Weight loss due to maldigestion/malabsorption - protocol

A

Hx
- any v+/regurgitation (ID which)/d+/change in faeces?
- simultaneous changes (e.g. diet: include treats/supplements/scavenging)
- parasite control: what, when, how?
- health of in contacts/family
- evidence of nausea: drooling, lip smacking

CE:
- extra attention to abdo palp
- pain (localise), thickened intestines, masses
- temp: look at faeces on thermometer
- hydration

Diagnostic tests:
- haem/biochem (including TLI, folate/B12)
- specific tests for common systemic dzs causing GI signs (e.g. TT4, basal cortisol)
- faecal exam (possibly culture, microscopy)
- imaging (US, fluoroscopy, endoscopy)
- diet trial
- biopsy

23
Q

Weight loss due to malutilisation - causes

A

Abnormal nutrient handling e.g.
- PLN
- DM
- liver dz

Increased demand for nutrients e.g.
- neoplasia
- hyperthyroidism
- infection
- cardiac cachexia
- parasites

24
Q

Weight loss due to malutilisation - other CS

A
  • usually systemically unwell: systemic signs beyond weight loss
25
Weight loss due to malutilisation - protocol
Hx - parasite control: what, when, how - changes to drinking or urinating - v+/d+ - coughing/sneezing/resp effort - changes to activity levels: decreased or increased - behaviour changes - appetite CE - thorough cardiac exam: HR, murmurs, dysrhythmias, pulses, CRT - resp assessment: mm colour, rr, resp sounds, dullness - abdo palp: pain, masses, thickened intestines, organomegaly - palpate LN and check for goitre - check temp Diagnostic tests - haem: anaemia? evidence of inflammation/infection? - biochem: liver/kidney parameters, Ca2+ - urinalysis: dipstick & USG, UPCR? - specific tests: TT4, fructosamine - x-ray/US/echo
26
Weight loss & appetite
As caloric demand not being met, dz causing weight loss often result in increased appetite unless underlying dz process also causes appetite to be overridden by negative factors commonly: - nausea - pain - stress
27
Weight loss with an increased appetite - causes
Particularly commonly associated with malabsorption or malutilisation. E.g. - DM - hyperthyroidism - neoplasia - cardiac cachexia - PLN - chronic GI dz - intestinal parasites
28
What is anorexia?
- not eating at all
29
What is hyporexia?
- not eating enough for normal maintenance
30
Causes of anorexia/hyporexia
Any conditions which can result in - loss of appetite - reluctance to eat and/or - mechanical inability to eat
31
Approach to anorexia: loss of appetite - approach & common causes
Approach: - signs of systemic dz on hx or CE? - particularly note drooling, pyrexia, pain - consider haematology/biochem/urinalysis - imaging as indicated - consider anti-emetic trial for possible nausea Common causes - renal/hepatic dz (toxin accumulation) - any inflammatory/infectious process causing pyrexia - neoplasia
32
Approach to anorexia: reluctance to eat - approach & common causes
Approach: - instigating factors: stressful event? - changes around feeding: location, bowl, other animals, diet? - general changes at home: new pets, building work etc - tempt to eat in other locations/with other food and monitor or improvement - consider consulting behaviourist Common causes - association of food with nausea/pain/stressful event e.g. hospitalisation - stressors e.g. other pets, building work, etc - change to less palatable diet e.g. prescription renal diet
33
Approach to anorexia: mechanical inability to eat - approach & common causes
Approach: - on exam able to open and close mouth normally? - tongue and oral soft tissues appear normal? - pain in neck/mouth/limbs - when does eat any issues chewing/swallowing/choking/drinking? - better with wet vs dry food or fed at a different height? - any sign of dental/oral pharyngeal dz/pain - may need sedation/GA to fully assess - often imaging for investigation (dental rads/x-ray) - consider pain relief trail? Common causes: - dental dz - gingivostomatitis - oral/pharyngeal/oesophageal masses
34
Anorexia - tx
- treat underlying condition - tempt to eat (beware of causing food aversions) - appetite stimulants (e.g. mirtazapine) - antiemetics if nausea (e.g. maropitant) - analgesia if painful conditions - minimise stress
35
What conditions can be associated with prolonged anorexia/hyporexia?
- GI disturbances: dysbiosis, intestinal hypo motility, reduced mucosal integrity - hepatic lipidosis - referring syndrome
36
Hepatic lipidosis - what is it? most at risk animals?
- peripheral fat mobilisation exceeds livers capacity to redistribute or use it - excess fat deposited in hepatocytes causing liver failure - mostly cats if rapid weight loss due to absolute/relative calorie deficit - increased risk if high BCS
37
Hepatic lipidosis - CS
- hepatomegaly - jaundice - lethargy - v+/d+ - ileus - hypersalivation - pallor - neck ventroflexion (due to lack of potassium) - coagulopathies
38
Hepatic lipidosis - diagnostic tests
Biochem: - increased ALT, ALP, AST Haem: - non-regenerative anaemia, poikilocytosis (abnormally shaped RBCs), increased Heinz bodies Coags: - possibly prolonged PT and APPT - low vit K: check and supplement before FNA or feeding tube US: - hepatomegaly: homogenous hyperechoic parenchyma Liver FNA: - significant vacuolar distension of hepatocytes
39
Hepatic lipidosis - tx
- IVFT: 0.9% NaCl NOT Hartmann's (can't metabolise lactate - supplement K+, phosphate and B12 according to biochem results - start feeding slowly: high protein low carb diet (tube feeding) - consider antiemetic: maropitant
40
Hepatic lipidosis - prognosis
- >80% recovery if tx started early
41
Refeeding syndrome - cause / pathophysiology
- if pt fed too much / too quickly after prolonged anorexia - starvation causes electrolyte depletion (notably Mg2+ & K+) - insulin released by pancreas when refeeding implemented - K+ and glucose co-transported into cells so serum K+ drops -> hypokalaemia - body responds so sudden reintroduction of carbs by making lots of ADP & ATP -> uses lots of phosphorus -> hypophosphataemia
42
Refeeding syndrome - CS
Seen within 5d of refeeding - cervical ventroflexion - severe muscle weakness - acute RBC lysis - resp failure
43
Refeeding syndrome - tx
Immediately reduce feeding 50% and lower carb diet and increase slowly over 4-6d Check electrolyte levels and give Potassium phosphate CRI as needed - may need Magnesium Sulphate too or hypokalaemia may be refractory - monitor electrolytes and glucose q4-6h and adjust accordingly - monitor PCV closely for hypophosphataemia induced haemolytic anaemia -> transfusion if needed - ECG: HR & rhythm
44
Refeeding syndrome - prevention
Reintroduce feeding slowly - Max speed: 1/3rd RER on day 1, 2/3rd RER on day 2, all day 3 Monitor K+, Mg2+ and phosphorus at least daily and supplement as needed
45
When to intervene re days of hyporexia/anorexia
1-2 days - monitor closely - create encouraged feeding plan 2-4 days - intervention required - unless recovery imminent - consider feeding tube during schedules procedures >5 days - intervention essential In cats intervention is essential at 3-4d due to risk of hepatic lipidosis
46
Intervention protocol for anorexic pt / pt unable to ear
Upper GIT functional - enteral nutrition likely for <5d -> nasooesphageal/NG tube - enteral nutrition likely for >5d -- if laparotomy indicated -> surgical gastrostomy tube -- if laparotomy not indicated -> PEG or oesophagostomy tube Upper GIT non-functional -> jejunostomy tube Entire GIT non-functional - if pt not malnourished and anorexia likely for <5d -> reassess daily for need for parenteral nutrition (3-5d anorexia) - if pt not malnourished and anorexia likely for >5d -> parenteral nutrition

Y4 SA - Abdominal & rectal disease (11 decks)

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