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Medicine II > Approach to GI disease and localization > Flashcards

Approach to GI disease and localization Flashcards

1
Q

Obj: Given a patient scenario, be able to categorize GI disease (acute vs chronic, primary vs secondary)

A
  • ​
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2
Q

Obj: Based on patient signalment, history, physical exam, and chronicity, determine the degree of testing and treatment required:

  • Recommend when empirical treatment is apprpriate
  • Recommend when additional diagnostics are needed
  • Recommend specific tests based on chronicity and disease severity
  • Recommend inpatient vs outpatient therapy
A
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3
Q

Obj: Given description of a patient’s clinical signs differentiate:

  • Vomiting vs regurgitation
  • small vs large intestinal diarrhea
A
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4
Q

Obj: Given results of GI “function” test choose the correct anatomic disease localization

A
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5
Q

What are the different ways of classifying GI Disease?

A
  • Anatomic
    • Primary vs Secondary (non-GI)
  • Temporal
    • <2-3wks = Acute
    • >3-4wks/ recurrent = Chronic
  • Mechanistic (diarrhea)
    • Osmotic, secretory, dysmotility, exudative, etc)
  • Disease category
    • Infectious, inflammatory, immune-mediated, etc
  • Treatment response
    • Food, nutrient, fiber or other microbiome-targeted, steroid, etc
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6
Q

What history is important when diagnosing GI disease?

A
  • Signalment
  • Normal diet & any changes
  • Vax/deworm status
  • Duration/Chronicity
  • Frequency
  • Description of event
  • Foreign body / Toxin ingestion
  • Travel History
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7
Q

What history is important when a patient presents w/ vomiting?

A
  • Association w/ eating/drinking
  • Time of last BM
  • Concurrent diarrhea
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8
Q

What PE findings are common w/ GI disease

A
  • Dehydration
  • Fever
  • Abdominal pain/distention
  • BCS
  • Signs of systemic disease
    • oral ulcerations, icterus, etc
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9
Q

What characteristics are common with Oral disease?

A
  • Ptyalism
  • Difficult food prehension, bolus formation, chewing
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10
Q

What are the Characteristics of Pharyngeal/Cricopharyngeal Disease

A
  • Impaired food passage through oropharynx
  • Gagging
  • Immediate reflux when swallowing
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11
Q

What are the Characteristics of Esophageal Disease?

A
  • Regurgitation
  • Repeated swallowing attempts
  • Ptyalism
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12
Q

What are the Characteristics of Gastric Disease?

A
  • Vomiting
    • Food 8-10hrs post-pradially suggests delayed gastric emptying
  • Nausea
  • Ptyalism
  • Dysrexia
  • Belching
  • Abdominal Distention/bloating
  • Cranial Abdominal pain
  • Weight loss ONLY if decreased intake (uncommon)
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13
Q

What are the characteristics of Intestinal Disease

A
  • Dysrexia
  • Nausea
  • Vomiting
  • Diarrhea
    • Small Intestinal diarrhea
    • Large Intestinal diarrhea
  • Constipation
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14
Q

How is SI diarrhea different from LI diarrhea

A
  • SI Diarrhea:
    • Normal - slightly increased frequency
    • Large volume
    • Lack of urgency
    • +/- Melena
    • +/- Vomiting
    • +/- Wt loss
    • +/- Flatulence
    • +/- Steatorrhea
  • LI Diarrhea:
    • Moderate - Severely increased frequency
    • Small volume
    • Urgency
    • Tenesmus
    • +/- Hematochezia
    • +/- Mucus
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15
Q

What are the characteristics of Rectal/Anal Disease?

A
  • Can be challenging to distinguish from LI Disease
  • Tenesmus
  • Dyschezia
  • Mucoid/hemorrhagic discharge
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16
Q

What are the goals for the Diagnostic approach to GI disease?

A
  • Define a patient’s severity of disease
  • Determine if there is a concern for an underlying surgical etiology
17
Q

What is the approach to diagnosing Acute Vomiting/Diarrhea w/ mild clinical signs

A
  • Abdominal radiographs - if NO diarrhea/BM, Hx of FB ingestion, non-productive retching, abdominal distention or pain
    • Labwork changes concerning for a proximal duodenal or pyloric outflow obstruction:
      • Hypochloremic metabolic alkalosis
        • HCl lost from the stomach w/out concurrent HCO3- loss from the duodenum
        • alkalosis worsened by renal compensation and resorption of HCO3- in place of Cl
    • Unproductive retching underscores importance of hx-taking
      • concern for gastric dilation and volvulus but can be confused w/ vomiting and nausea by owners
  • PCV/TS
  • +/- Fecal float
  • Symptomatic therapy: Hydrated, non-painful, no other systemic signs
18
Q

What is the approach to diagnosing Acute Vomiting/Diarrhea w/ Moderate-severe clinical or systemic signs

A
  • Rule-out non-GI disease: CBC, Biochemistry, UA
  • +/- Parvo testing
  • Fecal Float
  • Abdominal radiographs +/- Ultrasound
  • Select Cases:
    • Hypoadrenocorticism in dogs
      • baseline cortisol
      • +/- ACTH stimulation test
19
Q

What is the approach to diagnosing Chronic Vomiting/Diarrhea

A
  • Rule-out systemic (non-GI) disease
    • CBC, Biochem, UA
    • Hyperthyroidism in cats (tT4)
    • Hypoadrenocorticism in dogs
      • baseline cortisol +/- ACTH stimulation test
    • Select cases:
      • testing for pancreatitis or exocrine pancreatic insufficiency, portosystemic shunts (bile acids)
  • Fecal Float + empirical deworming (Fenbendazole)
  • Exclusion of additional enteropathogens, as warranted by patient signs and lab work
  • Abdominal Radiographs/Ultrasound:
    • Radiographs:
      • non-specific w/ chronic GI disease in Dogs/Cats
      • Decreased serosal detail
      • general GI distention w/ fluid/gas ( if decreased motility)
    • Ultrasound: Intestinal Wall changes
      • Increased thickness
      • Decreased layering
      • Mucosal hyperechogenicity
    • Allows for sampling of effusion, masses or enlarged ln, Ultrasound changes, (particularly in wall layering/thickness) are none specific - but can help prioritize differentials or plan how to obtain biopsies.
    • 30% of dogs/cats w/ idiopathic inflammatory Bowel Disease will have completely normal abdominal US findings
  • Perform GI-specific diagnostics and treatment trials
20
Q

Obj: Explain the utility and limitations of GI biopsies. Decide whether they should be recommended for a specific patient description and choose further testing or design a treatment plan based on results

21
Q

What criteria warrant additional evaluation for GI issues?

A
  • Dull/depressed patient mentation
  • fever
  • tachycardia/bradycardia
  • abdominal pain
  • melena
  • hematemesis
  • frequent or severe GI signs
  • PE abnormalities
  • Unresponsive to symptomatic treatment
22
Q

What is a “Gastrointestinal Panel”?

A
  • GI Function Testing
  • Combination of tests that help to rule out (or diagnose) pancreatic disease as a cause for GI signs. help localize Gi disease, and can help define severity of disease
  • Components:
    • Cobalamin (Vit B12)
      • Absorbed by receptors specifically located in the ileum
      • Decreased blood concentrations are usually associated w/ small intestinal (ileal), malabsorptive disease
      • TLI must be run when initially testing cobalamin levels in patients. The pancreas produces intrinsic factor, which is required for cobalamin-receptor binding.
        • Low cobalamin + low TLI = decreased absorption
          • due to exocrine pancreatic insufficiency (decreased intrinsic factor production_ and NOT small intestinal disease
      • Methylmalonic acid (MMA) is a more sensitive test for cellular/functional cobalamin deficiency
        • Elevated MMA blood concentrations suggest cobalamin deficiency even if blood cobalamin concentrations are normal
        • MMA is not available as a combined test on the “GI Panel” can be performed separately in dogs and cats
    • Folate:
      • absorbed in the proximal GI tract (duodenum)
      • Decreased blood concentrations are associated with proximal SI malabsorptive disease
    • Pancreatic Lipase immunoreactivity (pancreatic specific lipase; specPL)
      • increased specPL is associated with pancreatitis
    • Trypsin-like immunoreactivity (TLI)
      • Decreased TLI is diagnostic for exocrine pancreatic insufficiency
23
Q

When should Biopsies be recommended for chronic GI disease?

A
  • No single criterion
  • Patients with more severe signs or multiple factors
  • Clinical signs:
    • Inappetence
    • lethargy
    • Progressive weight loss
    • Treatment trial failure, PRIOR to steroids
  • Biochemical or imagining findings
    • Hypoalbuminemia
    • Hypocobalaminemia
    • GI abnormalities on ultrasound
    • Clinical suspicion of infectious or neoplastic etiology
24
Q

What are the Benefits/Risks of taking GI biopsies through surgery?

A
  • Benefits:
    • full-thickness biopsies
    • Ability to biopsy all of small intestine or feel focal lesions
    • ability to biopsy lymph nodes and other organs
  • Risks:
    • Decreased healing and dehiscence w/ diffuse, infiltrative disease or hypoalbuminemia
    • Colonic biopsies usually NOT performed
    • More invasive procedure and increased healing time compared to endoscopy
25
Q

What are the benefits/risks of taking biopsies through endoscopy?

A
  • Both upper (stomach and duodenum) and lower (ileum and colon) GI biopsies are recommended.
    • may have different diagnosis in each portion
  • Benefits:
    • Able to visualize internal lesions
    • Safter to obtain colonic biopsies and less risk in patients with diffuse, infiltrative disease or hypoalbuminemia
    • Out-patient procedure
  • Risks:
    • Partial thickness, small biopsies may miss the diagnosis
    • Inability to reach all parts of the GI tract or visualize focal lesions that are not intraluminal
    • Histopathologic severity does NOT predict response to treatment for Idiopathic inflammatory enteropathies but more severe changes are prognostic
    • Difficult to distinguish small cell lymphoma from severe inflammatory Bowel Disease
26
Q

What are the possible Histopathologic findings in Idiopathic inflammatory Bowel Disease

A
  • Lymphoplasmacystic inflammation **
  • Concern for neoplasia?
    • can perform PCR for antigen receptor rearrangement (PARR)
      • help distinguish IBD from small cell lymphoma
        • clonal results being consistent with small cell lymphoma
  • Neutrophilic inflammation
    • consider fluorescent in situ hybridization (FISH)
    • consider testing for Campylobaceter in cats
  • Eosinophilic inflammation
    • repeat deworming
    • consider diet trial
  • Pyogranulomatous
    • fungal or atypical bacteria search
  • Histopathologic score is prognostic
  • NONE of these patterns are specific for a certain diseae or treatment response.
27
Q

What are the limitations of GI biopsies?

A
  • Do not differentiate between treatment responses
    • diet, microbiome-targeted, steroids
  • Only 30% agreement between duodenal and ileal biopsies
  • Histopathologic severity does not correlate with clinical sign severity
  • Microscopic changes do not resolve with treatment

Medicine II (46 decks)

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