Diseases of the Gastrointestinal System Flashcards
what are the clinical signs of oropharyngeal disease?
drooling saliva +/- blood
halitosis
dysphagia +/- odynophagia
what is ptyalism?
overproduction of saliva
what is pseudoptyalism?
normal production of saliva but unable to keep it in mouth/swallow it
what is odynophagia?
painful swallowing
how can you investigate oral disease?
physical examination - may require sedation/GA
radiographs
minimum database
FNA and/or biopsy
what does chelitis mean?
inflammation of the lips
what does glossitis mean?
inflammation of the tongue
what does gingivitis mean?
inflammation of the gums
what does stomatitis mean?
inflammation of the oral mucosa
what is gingivostomatitis?
inflammation of the gums and oral mucosa
what types of malignant neoplasia are seen in the mouth?
squamous cell carcinoma
malignant melanoma
sarcomas
how is oropharyngeal disease treated?
depends on underlying cause! surgery for neoplasia surgery/wound management for trauma foreign body removal anti-inflammatories antibiotics
what are the nursing considerations for oral disease?
specific diagnosis/treatment of underlying disease
analgesia (opioids, NSAIDs)
providing warm/wet/soft food OR considering bypass/tube feeding
barrier nursing for infectious aetiologies
what does odynophagia mean?
swallowing pain
what is regurgitation?
passive return of food (hallmark of oesophageal disease)
what is vomiting?
an active, forceful, reflex ejection of gastric and upper intestinal content
following stimulation of a neural reflex
that has synaptic centres in the brainstem
what does regurgitated material usually consist of?
undigested food +/- mucus/saliva covering
what are the possible secondary problems/complications of regurgitation?
malnutrition and dehydration
anorexia or (perceived) polyphagia
reflux pharyngitis/rhinitis
aspiration pneumonia
what is reflux pharyngitis/rhinitis?
regurgitation contents making their way into the nasal cavity and causing inflammation
how can oesophageal disease be investigated?
physical examination
chest x-rays (must be conscious)
lab tests - haematology and serum
biochemistry
oesophagoscopy
what are the 3 types of oesophageal disease?
megaoesophagus
oesophagitis
oesophageal obstruction
what are the 3 types of oesophageal obstruction?
intraluminal
intramural
extraluminal
what is megaoesophagus?
oesophageal dilation and dysfunction
what causes generalised megaoesophagus?
usually idiopathic
can be myasthenia gravis
what can cause focal dilation of the oesophagus?
vascular ring anomaly
how is megaoesophagus treated?
no cure if idiopathic - supportive treatment only
neostigmine and pyridostigmine for myasthenia gravis
surgery for vascular ring anomaly
what is involved in nursing management of megaoesophagus?
postural feeding - stairs/work surface, bailey chair
slurry vs. textured food - individual differences
what are the most common complication of megaoesophagus? how is it treated?
aspiration pneumonia - tachypnoea, pyrexia, lethargy, inappetence
treat with IV antibiotics
what is oesophagitis?
inflammation of the oesophagus?
what can oesophagitis be caused by?
caustics
hot liquids/foods
foreign bodies
irritants (e.g. doxycycline stuck in throat)
GOR/persistent vomiting
what can oesophagitis lead to?
oesophageal strictures
why might GOR occur?
during anaesthesia - relaxing of sphincters
persistent vomiting
hiatal hernia
GERD (heartburn) - spontaneous reflux, possibly due to obesity or BOAS
what are the signs of oesophagitis?
regurgitation
hypersalivation
anorexia, weight loss
pain
how is oesophagitis managed?
oesophageal rest - soft, bland, low fat food in small amounts
analgesia (topical vs systemic)
liquid antacid gels/coating agents
acid blockers (omeprazole)
drugs to reduce further reflux (metaclopramide, cisapride)
how is an oesophageal foreign body removed?
usually endoscopically
fluoroscopically
surgery
how does oesophageal stricture occur?
fibrosis after severe ulceration of mucosa
how can oesophageal stricture be treated?
balloon dilation
what is emesis?
vomiting
what is haematemesis?
vomiting blood
what is haematochezia?
fresh blood in/on faeces/diarrhoea
what is malaena?
faecal passage of undigested blood
what is diarrhoea?
increased faecal water content
what is tenesmus?
straining to pass faeces
what is dyschezia?
difficulty passing faeces
what is an emetic?
a substance that stimulates vomiting
what is an anti-emetic?
substance that inhibits vomiting
does vomiting involve gastric contraction?
no
what are the 4 stages of vomiting?
- Prodromal (nausea)
- Retching
- Expulsion
- Relaxation
what is involved in the prodromal phase of vomiting?
nausea restlessness, agitation hypersalivation gulping lip-licking/smacking
what is involved in the retching stage of vomiting?
inhibition of salivation
simultaneous, uncoordinated, spasmodic
contractions of respiratory muscles
duodenal retroperistalsis
mixing of gastric contents
what is involved in the expulsion phase of vomiting?
pyloric contraction and fundic relaxation
relaxation of proximal stomach and lower oesophageal sphincter
protection of airway (closure of glottis and nasopharynx)
abdominal contraction and descent of diaphragm with reduced oesophageal sphincter tone
what is involved in the relaxation phase of vomiting?
relaxation of abdominal, diaphragmatic and respiratory muscles
re-opening of the glottis and nasopharynx
return of breathing
how can you identify small intestinal diarrhoea?
large volume, watery
normal frequency
often normal colour
+/- melaena
how can you identify large intestinal diarrhoea?
small volume
increased urgency and frequency
tenesmus, dyschezia
+/- mucus and/or blood
which part of the GI tract does gastritis refer to?
stomach
which part of the GI tract does enteritis refer to?
small intestine
which part of the GI tract does colitis refer to?
large intestine
which part of the GI tract does gastro-enteritis refer to?
stomach and small intestine
which part of the GI tract does entero-colitis refer to?
small and large intestine
which parts of the GI tract does gasto-entero-colitis refer to?
stomach, small and large intestine
what are the important questions for phone triage for patients with vomiting/diarrhoea?
productive/non-productive vomiting
frequency - gauge fluid losses
foreign material
haematemesis/melaena?
small or large intestinal?
when would you advise consultation for diarrhoea/vomiting?
unproductive vomiting
large fluid volumes lost
haematemesis/melaena
suspicion for foreign material ingestion
inappetant/hypodipsic
other systemic signs
puppy/kitten
what are the categories of acute vomiting and diarrhoea?
- non-fatal, often trivial, may or may not require specific treatment
- severe and potentially life-threatening
- surgical disease
what can cause non-fatal/trivial vomiting and diarrhoea?
dietary indiscretion
parasitism
enteric infection
adverse drug event
what can cause severe and potentially life-threatening diarrhoea and vomiting?
pathogenic enteric infections (parvo, bacterial)
acute haemorrhagic diarrhoea syndrome
acute pancreatitis
surgical disease
intoxications
what types of surgical disease can cause acute vomiting and diarrhoea?
intusussception GDV incarceration stricture/partial obstruction foreign body
(usually vomiting is the major problem in surgical disease)
what are the possible consequences of vomiting and/or diarrhoea?
dehydration
hypovolaemia
acid-base disturbance
aspiration pneumonia
what diagnostic tests can be done for acute gastroenteritis?
history, physical examination
bloods - haematology, biochemistry, electrolytes
faecal infectious disease testing
imaging
response to symptomatic treatment/surgical management
how can you maintain hydration in a V/D animal?
IV Hartmann’s in clinic
oral rehydration solutions if at home - glucose/electrolyte/glutamine-containing solutions
water usually sufficient
what dietary advice should be given to owners with vomiting animals?
if acute vomiting, rest the gut 24-36hrs but provide free access to water
re-introduce bland diet little and often
transition to normal diet over 2-5 days
not suitable for neonates or diabetic patients
what dietary advice should be given to owners of animals with diarrhoea?
feed through diarrhoea - quicker recovery and reduces potential of sepsis
what supportive/symptomatic support is available for V/D patients?
antiemetics - exlcude obstruction first
antispasmodics e.g. buscopan
anti-diarrhoeals - cosmetic only (kaolin based)
how can you treat acute vomiting/diarrhoea?
antithelmintics if puppy/kitten or is adult and not recently wormed
antibiotics rarely indicated - consider if haemorrhagic diarrhoea +/- pyrexia
pre/probiotics may or may not have effect - safer than unnecessary antibiotics
why can’t NSAIDS be given to V/D patients?
prostaglandins required for maintenance of GI mucosal integrity
maintenance of renal blood flow in hypovolaemic states
are NSAIDs contraindicated for V/D use?
yes ALWAYS
what nursing considerations should be taken with acute gastroenteritis?
patient hygiene - clean/dry bottom, avoid over-grooming, tail bandage
environmental hygiene - appropriate waste disposal, appropriate washing/disinfection of contaminated items
appropriate PPE
barrier nursing if possibly infectious
kennel signage
how can a smooth, small gastric FB be treated?
induce emesis
what is used to induce emesis in dogs?
apamorphine
what is used to induce emesis in cats?
xylazine
how is a non-obstructive intestinal FB treated?
wait for natural passage with radiographic monitoring
how is an obstructive FB treated?
usually surgery
what is GDV?
gastric dilation-volvulus - acute dilation and torsion of the stomach
why is GDV dangerous?
can occlude the caudal vena cava which causes impaired venous return and compromised mucosa - leading to shock and death
which dogs are more likely to suffer with GDV?
deep-chested breeds
what are the causes of GD/GDV?
not completely sure
could be diet, aerophagia, delayed emptying, exercise timing
how is GD/GDV treated?
aggressive fluid therapy
immediate decompression via a stomach tube
IV antibiotics if compromised stomach wall
surgical correction (derotation +/- gastropexy)
what are the possible parasitic causes of acute/chronic vomiting and/or diarrhoea?
roundworms
hookworms
whipworms
cestodes
what are the possible protozoal causes of acute vomiting and/or diarrhoea?
coccidia spp. - only problematic in puppies/kittens/coinfections
giardia spp. - affects young dogs and cats, possibly zoonotic
Tritrichomonas foetus
what is tritrichomonas foetus?
protozoal infection of young cats
what are the GI signs of tritrichomonas foetus infection?
intractable diarrhoea
+/- perianal oedema
+/- faecal incontinence
how is tritrichomonas foetus infection diagnosed?
colonic wash and PCR
how is tritrichomonas foetus treated?
poorly responsive to treatment (ronidazole)
environmental management
will mount an effective immune response with maturation
what are the pre-disposing features for idiopathic pancreatitis?
dietary indescretion
hyperlipaemia
impaired perfusion
trauma/handling
how does acute pancreatitis cause disease?
local release of pancreatic enzymes leads to pancreatic autodigestion
causes severe local inflammation with pain
what are the signs of acute pancreatitis?
range from mild to fatal
inappetence, lethargy
severe abdominal pain, vomiting, diarrhoea
+/- jaundice (bile duct obstruction)
dogs may adopt prayer position
how is acute pancreatitis diagnosed?
history and physical examination
imaging (radiography and ultrasound)
haematology, serum biochemistry
pancreatic lipase immunoreactivity test
what is the treatment for acute pancreatitis?
fluid support
nutritional support - feeding is beneficial, oral v.s tube feeding
analgesia
antiemetics
what is the prognosis for acute pancreatitis?
highly variable to guarded
death is possible
recurrence is possible
when/ how should pancreatitis patients begin drinking/eating again?
frequent, small amounts of water once vomiting controlled
slowly reintroduce highly digestible complex carbohydrate food
low fat food if hyperlipaemic or repeated bouts
how does chronic pancreatitis occur?
results from repeated attacks of acute pancreatitis
what are the signs of chronic pancreatitis?
causes chronic, recurrent, grumbling GI signs
inappetence, lethargy
vomiting and/or diarrhoea
how is chronic pancreatitis managed?
at-home dietary modification
manage nausea/appetite
analgesia (not NSAIDs!)
what is anorexia?
a loss of desire to eat, despite being physically able to
what is hyporexia?
reduced appetite?
what is polyphagia?
excessive appetite
what is pica?
appetite for non-nutritional substrates e.g. licking concrete/metals
what are the secondary complications of prolonged anorexia?
weight loss
impaired immune function
increased risk of sepsis
poor wound healing and slow recovery
what is borborygmi?
gurgling sounds
what is flatus?
passing wind
what is ileus?
reduced gastro-intestinal motility
what duration is considered chronic vomiting/diarrhoea?
> 3 weeks
what are the signs and findings with chronic GI disease?
altered appetite dehydration vomiting +/- blood diarrhoea +/- blood weight/condition loss borborygmi, flatus abdominal discomfort
what are some possible causes of chronic vomiting and/or diarrhoea under primary GI disease?
gastric ulceration
dietary intolerance/sensitivity
inflammatory e.g. IBD
neoplastic e.g. gastric carcinoma, GI lymphoma
what are some causes of chronic V/D which are secondary to extra-GI disease?
liver disease
kidney disease
pancreatitis (chronic)
endocrine disease (hyperthyroidism in cats, hypoadrenocorticism in dogs)
how might chronic V/D be approached diagnostically?
history and clinical examination haematology and serum biochemistry basal cortisol, total thyroxine pancreatic tests faecal analysis absorption tests (B9 and B12) imaging (radiographs and ultrasound) gastroscopy/laparotomy and biopsy
what is the basal cortisol test?
test for adrenal gland function
what is the total thyroxine test?
test for thyroid gland function
what other imaging might be used if endoscopy is unavailable?
contrast radiography
what are the disadvantages in using contrast radiography for exploring chronic V/D?
messy
time-consuming
difficult to interpret
often done poorly
what are BIPS? what is it used for?
barium impregnated polyethylene spheres
used in place of ingesting/injecting barium powder/fluid
why might ultrasound be used for investigating chronic V/D?
identifying masses, intussusceptions and measuring GI wall thickness
evaluate lymph nodes for free fluid
what are the 2 methods of obtaining an intestinal biopsy?
laparotomy - full thickness biopsies
endoscopy - superficial, may not reflect jejunal disease
which diseases are part of the inflammatory bowel disease (IBD) complex?
food-responsive
antibiotic responsive
true idiopathic inflammatory bowel disease
which breed is most likely to suffer from antibiotic responsive disease?
german shepherds
what are chronic enteropathies?
chronic disease of the small intestine
what is protein-losing enteropathy?
a form of chronic enteropathy
–> severe SI disease resulting in severe malabsorption and loss of albumin and globulin
what are the signs of protein-losing enteropathy?
severe weight loss
oedema and ascites due to reduced oncotic pressure of blood
risk of thromboembolic events
what causes protein-losing enteropathy?
various causes - IBD, lymphangiectasia, alimentary lymphosarcoma/lymphoma
how is protein-losing enteropathy diagnosed?
endoscopy
what are the commonly used therapies for supporting chronic V/D?
exclusion of parasitism - fenbendazole course
dietary modification
vitamin B12
steroids
anti-emetics
appetite stimulants
what are the dietary considerations for those with food intolerances/hypersensitivity?
avoidance of allergen
hydrolysed diets
what are the general principles re. diet in chronic V/D?
highly digestible
restricted fat in GOR/delayed gastric emptying
supplementary fibre
little and often
what considerations need to be made regarding inappetent patients?
in pain or stressed? dehydrated hypokalaemic hypocobalaminaemic nauseous delayed gastric emptying
how can we encourage food intake in chronic V/D patients?
avoid introducing prescription diets in the hospital
warm, wet and odorous food
check with owner about individual preferences
ensure euhydrated with balanced electrolytes
what medical therapies are available for inappetence?
nausea control - maropitant, metoclopramide
appetite stimulants - mirtazepine
consider effects of other drugs - opioids reduce GI motility, NSAIDs cause GI irritation and erosion
how can you supplement cobalamin (B12)?
subcutaneous injections weekly for 4-6 weeks until normalised
oral mega-dose
re-measure serum cobalamin after 4-6 weeks
what is exocrine pancreatic insufficiency?
failure of normal exocrine pancreatic secretion (enzymatic)
what causes exocrine pancreatic insufficiency?
usually due to pancreatic acinar atrophy (esp german shepherds)
may be due to recurrent pancreatitis (cats)
what are the signs of exocrine pancreatic insufficiency?
extreme polyphagia
diarrhoea, typically fatty/greasy
severe weight loss
how is EPI diagnosed?
trypsin-like immunoreactivity serum test (species-specific)
how is EPI treated?
no cure - expensive and lifelong management
oral pancreatic extract - uncoated powder or fresh frozen pancreas
what diet should you feed animals with EPI?
2-3 meals a day, always with enzyme
highly digestible food
high protein
non-complex carbohydrates
cobalamin supplementation required in many
what is colitis?
colonic inflammation resulting in large bowel diarrhoea
how is colitis treated?
sulphasalazine (contraindicated in SI disease) - local anti-inflammatory
what is the major side effect of sulphasalazine?
keratoconjunctivitis sicca (dry eyes)
what is irritable bowel syndrome?
large intestinal pattern diarrhoea +/- occasional vomiting
how is IBS diagnosed?
by exclusion of other causes of signs
what is the treatment for IBS?
long-term dietary modification
anti-spasmodics
anti-cholinergics
why might there be blood in the faeces or vomit?
coagulopathy
swallowed blood
gastric/SI bleeding (haematemesis, melaena)
LI bleeding (haematochezia)
what are the possible causes of GI ulceration?
drugs (NSAIDs, steroids)
direct trauma from a foreign body
neoplasia (gastric carcinoma)
hypoadrenocorticism
kidney disease
liver disease
how should gastric ulcers be treated?
evaluate for and remove/treat underlying cause
acid blockers
coating agents (sucralfate)
analgesia
surgery if perforated
what types of acid blockers can be used to help treat gastric ulcers?
proton pump inhibitors (omeprazole)
histamine receptor agonists
antacids
what condition can a perforated gastric ulcer lead to?
septic peritonitis
what is constipation?
impaction of the colon or rectum with faecal material
what can prolonged constipation lead to?
obstipation
what is obstipation?
intractable constipation
what are the signs of constipation?
infrequent defecation
dyschezia and tenesmus
pain associated with unsuccessful defecation
vomiting, anorexia, lethargy
what are some of the possible causes of constipation?
dietary
dehydration
drug-related
environmental (stress, lack of toileting opportunities)
pain/orthopaedic problems - inability to posture
spinal/neuromuscular disease
pelvic canal obstruction
perineal/perianal disease
how can constipation be treated?
identify and correct underlying cause
fluid therapy +/- electrolyte correction
oral laxatives, enemas
motility modification
surgery (cause dependent)
how can constipation be avoided?
ensure adequate water intake
dietary modification (fibre)
litter tray management
increased exercise
motility modification (cisapride) laxatives
what is megacolon?
loss of neuromuscular function of the colon producing weakened colonic contractions and faecal overload
which animals most commonly suffer from megacolon?
cats - idiopathic
how can megacolon be treated?
treat as for constipation
last resort is sub-total colectomy
what are the main synthesis products of the liver?
proteins - albumin, globulin, clotting factors
glucose
cholesterol
what kinds of clearance/detoxification are involved in normal hepatic function?
encephalopathic toxins (ammonia)
bilirubin
bile acids
enterically absorbed drugs
what are some of the possible clinical signs of hepatic dysfunction?
inppetance, lethargy, V/D
jaundice
ascites
hepatic synthetic and/or detoxification failure
what is icterus?
yellow discolouration of the skin/mucous membranes/eyes due to hyperbilirubinaemia
what is hyperbilirubinaemia?
increased bilirubin in the blood
>10umol/L
at what level does tissue deposition of bile pigment become apparent?
> 40umol/L
what is a pre-hepatic cause of jaundice?
haemolysis (moderate-severe)
what is a hepatic cause of jaundice?
failure of hepatic uptake, conjugation and/or transport of bilirubin
what are the possible post-hepatic causes of jaundice?
failure of excretion of bile
cholestatic disease
biliary rupture
what are the causes of ascites (in terms of liver disease)?
hypoalbuminaemia
portal hypertension
sodium and water retention
what can hepatic dysfunction/abnormal blood supply to the liver lead to?
failure of conversion of ammonia to urea, leading to hyperammonaemia and/or hepatic encephalopathy
failure of drug detoxification
what are the signs of forebrain dysfunction?
lethargy obtundation head pressing pacing, walking in circles seizures coma
what can build up in the blood which leads to forebrain dysfunction?
encephalopathic toxins
after which events will a hepatic encephalopathy be worse?
high protein meal
GI haemorrhage
what are the precipitating events for hepatic encephalopathy?
feeding high protein meal
vomiting, diarrhoea
diuretics
what are the laboratory tests for liver disease?
liver enzymes bilirubin bile acids blood glucose blood clotting parameters
how can liver disease be diagnosed?
laboratory testing
imaging
liver cytology/biopsy
what are the most common causes of acute liver disease?
toxins or infections
which ingested toxins can cause acute liver disease?
xylitol
mushrooms
blue green algae
which drugs can cause acute liver disease?
phenobarbitone paracetamol azathioprine doxycycline lomustine
which infections can cause acute liver disease?
leptospirosis
ascending biliary infection
canine adenovirus
what are the main nursing considerations for acute liver disease?
management of hepatic encephalopathy
anti-emetics (may be feeling nauseous)
management of hypoglycaemia
may be coagulopathic - consider implications of venepuncture
barrier nursing if infectious cause
where should venepuncture be performed in patients with acute liver disease?
ideally leg - patient may be coagulopathic and you can’t apply a pressure bandage to the jugular vein
how do you manage hepatic encephalopathy?
lactulose - oral or retention enema
+/- seizure management
monitor/maintain normal hydration and electrolytes (esp K)
what is involved in nutritional management of liver disease?
restricted animal protein diet - otherwise hepatic prescription diets
copper restricted
antioxidant supplemented
what are the sterile causes of inflammatory liver disease?
chronic hepatitis (dogs) lymphocytic cholangitis (cats)
what are the infectious causes of inflammatory liver disease?
cholangitis/cholangiohepatitis - chronic or acute
chronic/acute leptospirosis (dogs)
feline infectious peritonitis - chronic
what are the specific treatments for inflammatory liver disease?
de-coppering therapy
antibiotics - only where specifically indicated
what are the general treatments for inflammatory liver disease?
dietary modification
liver supportive therapies (anti-oxidants)
anti-inflammatories (steroids)
choleretics
hepatic encephalopathy therapies
ascites management (spironolactone)
what are choleretics?
substances which increase the volume of secretion of bile from the liver as well as the amount of solids secreted
what chelating agents are used in de-coppering therapy?
D-penicillamine
zinc therapy for longer term use
how can copper intake be restricted?
dietary - prescription diet, avoid red meat, offal, eggs, cereals
consider water source - copper in old pipes
which antioxidants can be used in inflammatory liver disease management?
silymarin/silibinin/sylibin (milk thistle)
SAMe
which synthetic choleretic is used in inflammatory liver disease management?
ursodeoxycholic acid (UDCA)
how does UDCA work?
stimulates bile flow, modulates inflammatory response in liver
what is UDCA?
a synthetic, hydrophilic ‘beneficial’ bile salt (choleretic)
what is gall bladder mucocoele?
where the gall bladder is full of inspissated bile and mucus - can cause blockage
what does a gall bladder mucocoele look like?
kiwi fruit appearance
what is feline hepatic lipidosis?
hepatocyte triglyceride deposition - leads to massive intracellular fat accumulation
what are the predispositions for feline hepatic lipidosis?
obesity
high fat/carbohydrate diet
systemic illness
diabetes mellitus
what can feline hepatic lipidosis progress into?
liver failure - encephalopathy and coagulopathy
how is feline hepatic lipidosis diagnosed?
FNA - check clotting first
monitor CVS parameters post-procedures
what is the treatment for feline hepatic lipidosis?
treat the underlying disease
nutritional support
antioxidants
UDCA
L-carnitine
never force-feed/syringe feed a cat!
what are the usual blood findings with a congenital portosystemic shunt?
low albumin
low cholesterol
high bile acids
high ammonia
how is a portosystemic shunt diagnosed?
ultrasound
what is a portosystemic shunt?
an extra vessel which passes blood from the portal vein straight into the caudal vena cava, bypassing the liver
what can occur due to portovascular anomalies?
liver dysfunction due to lack of nutrient supply
accumulation of toxins leading to hepatic encephalopathy
how can a portosystemic shunt be treated short-term?
ensure well hydrated with normal K levels restricted protein diet lactulose to trap ammonia in colon antibiotics \+/- anti-seizure therapy
what is the ideal long-term solution for a portosystemic shunt?
surgical closing of shunted vessel
what are the signs of hepatic neoplasia?
asymptomatic
primary hepatic/obstructive signs
rupture –> haemoabdomen
what are the types of hepatic neoplasia?
primary tumours - surgery
infiltrative - chemo
metastatic - no treatment as has already spread from elsewhere
