Gastroenterology Pt. 1

Question 1

examples of non-specific GI signs

Answer 1

¡ Usually accompany more specific signs
¡ Occasionally the only signs

• Lethargy(depression)
• Non-localizablepain
• Hyporexia(inappetence),anorexia
• Dehydration
• Weightloss

Question 2

if client says patient is vomiting, what should we wondder?

Answer 2

– Is it vomiting or regurgitation?– Is it GI or extra-GI in origin?

Question 3

vomiting vs regurgitation: basic difference / way to differentiate

Answer 3

Vomiting active, regurgitation passive

Look at signs:
abdominal effort
Prodromal nausea
Character of ejected food
Timing of food ejected
Swallow attempts of a single bolus
Ability to drink
Pain on swallowing
Associated signs

Question 4

vomiting vs regurgitation: abdominal effort

Answer 4

Regurgitation: none
vomiting: marked

Question 5

vomiting vs regurgitation: prodromal nausea

Answer 5

Regurgitation: none
vomiting: present

Question 6

vomiting vs regurgitation: character of ejected food

Answer 6

Regurgitation: undigested food (typically)
vomiting: usually digested

Question 7

vomiting vs regurgitation: timing of food ejected

Answer 7

Regurgitation: variable
vomiting: variable

Question 8

vomiting vs regurgitation: Swallow attempts of a single bolus

Answer 8

regurgitation: usually single
vomiting: single

Question 9

vomiting vs regurgitation: ability to drink

Answer 9

regurgitation: variable
vomiting: normal

Question 10

vomiting vs regurgitation: pain on swalling

Answer 10

regurgitation: possible
vomiting: absent

Question 11

vomiting vs regurgitation: associated signs

Answer 11

regurgitation: dyspnea, cough
vomiting: +/- systemic signs

Question 12

what type of problem may accompany esophogeal motility problem

Answer 12

dysphagia (difficulty swallowing)

Question 13

what often accompanies vomiting in cats

Answer 13

-retching

Question 14

why is quality of expelled material of limited utility to differentiate regurgiation from vomiting?

Answer 14

¡ Quality of expelled material somewhat limited utility because esophageal reflux may move stomach contents into esophagus
¡ Degree of digestion
¡ Digested versus fresh blood
¡ pH
¡ Bile

Question 15

if in doubt about regurgitation vs vomiting…

Answer 15

¡ If in doubt – thoracic radiographs

Question 16

gastrointestinal vs extra-gastro-intestinal causes of vomiting

Answer 16

1. vestibular system acts on chemoreceptor trigger zone…
2. higher CNS centres…
3. vagal and sympathetic visceral afferents…
   >all act on the vomiting centre in medulla
   >motor impulses to upper GI tract and diaphragm/abdominal muscles

Question 17

differential diagnoses for acute vomiting

Answer 17

¡ “Acute gastritis”
¡ GI foreign body (always a DDx)
¡ Acute pancreatitis (always a DDx)

Question 18

how do we diagnose acute gastritis

Answer 18

• Self-limiting vomiting
• Diagnosis of exclusion
• Occasionally endoscopic biopsy

Question 19

6 causes of acute vomiting

Answer 19

-FB (stomach, intestinal)
-Acute gastritis (infectious, toxin, drugs, dietary indiscretion, other)
-Ileus
-Pancreatitis
-Renal failure, acute or chronic
-Addison’s disease

Remember to think of GI and extra-GI causes

Question 20

6 causes of acute regurgitation

Answer 20

-FB (esophagus)
-Acute esophagitis (caustics, previous vomiting, previous FB)
-Esophageal dysmotility, megaesophagus
-Esophageal stricture (more chronic)
-Hiatal hernia (more chronic)
-Addison’s disease

Remember to think of GI and extra-GI causes

Question 21

in a case of acute vomiting, do we go with conservative management versus work-up and hospitalization?

Answer 21

-can start with conservative management
-Small volume frequent oral fluids, ice chips, SC fluids
- “Bland diet”

§ If any worsening of signs -> work-up and hospitalization

Question 22

what does conservative management of acute vomiting entail?

Answer 22

¡ Small volume frequent oral fluids, ice chips, SC fluids
¡ “Bland diet”
>Easily digested, reduced fat & fibre (see Diarrhea)
Ø Commercial – numerous “prescription” GI diets
Ø Home-made – e.g. cottage cheese, boiled chicken/hamburger, rice, potato

Question 23

What about use of antiemetics in conservative management? when is it ok? concerns?

Answer 23

¡ Okay to use so long as short-term & recheck

¡ Concerns
* Promoting obstruction (metoclopramide)
* Masking foreign body (Cerenia product warning)
* Masking more serious disorder

Question 24

Factors promoting workup and/or hospitalization for acute vomiting

Answer 24

¡ Vomiting moderate-to-severe
¡ Duration > 72 hours, especially if moderate-to-severe
¡ Known exposure to foreign material or toxin
¡ Older animal, especially if no previous GI history
¡ Owner desires, even though overkill (always offer)
¡ Depression, impression that animal is sick
¡ Fever
¡ Moderate-to-severe dehydration
¡ Shock
¡ Moderate-to-severe abdominal pain
¡ Abdominal distension, especially if breed prone to GDV
¡ Hematemesis, melena (proximal GI tract bleeding)
¡ Abdominal mass
¡ Any sign suggesting an extra-GI cause

Question 25

lab workup for vomiting? purpose of this?

Answer 25

Routine CBC & biochemistry profile for vomiting and/or diarrhea (acute & chronic)

Purpose of lab work is to:
1) Help rule-out non-GI causes of V/D
eg. Kidney, pancreatic, or liver disease
2) Characterize severity of dehydration and electrolyte imbalances resulting from V/D
3) Potentially localize GI lesion (not often)
4) Often does not help with specific diagnosis of cause of GI signs

Question 26

will labwork often help with specific diagnosis of cause of GI signs?

Answer 26

Often does not help with specific diagnosis of cause of GI signs

Question 27

how useful is radiology for work-up in acute vomiting case?

Answer 27

¡ Common and useful in work-up of acute vomiting

Question 28

purpose of barium with radiology for acute vomiting

Answer 28

Use barium only to detect delayed gastric emptying and intestinal obstruction
* Use of barium much lower where ultrasound available
* Barium may prevent endoscopy

Question 29

what do we look for in a radiograph in a vomiting case?

Answer 29

• normal pyloris?
  -foreign material?
• ileus - distended loops of intestine (can be obstructive or inflammatory)
• Plication with small gas bubbles– linear FB (watch out for normal plications in cats)
• GDV – gas-distended stomach with “shelf”

Question 30

should we interpret thickness of intestines to diagnose cause of vomiting? why?

Answer 30

Do NOT interpret thickness of intestines: appearance of thickness depends upon fat outside intestinal wall and fluid inside lumen

Question 31

when is ultrasound useful in a vomiting case

Answer 31

¡ Utility in animals with acute vomiting

• Gastric emptying and ileus
  vAssessment of motion
  vFluid accumulation
• Thickness of stomach wall and intestines
  vMore useful in chronic vomiting
  vAssess for ulceration
• Assessment for foreign material
  ¡ < radiology for gastric foreign bodies
  ¡ Excellent for small intestinal foreign bodies

Question 32

Gastric foreign body management options

Answer 32

Each approach has risks & benefits
* Induce vomiting if recently witnessed
* May pass on its own
* Endoscopy
* Surgery

Question 33

induced vomiting for gastric foreign body: when to use, risks

Answer 33

Induce vomiting if recently witnessed
vSmall risk of aspiration
vSmall risk getting stuck in esophagus

Question 34

pros and cons of letting GI foreign body pass on its own

Answer 34

Maypassonitsown
vBut less complicated Sx if not obstructed or perforated (sharp FB)

Question 35

pros and cons for endoscopy for gastric foreign body management

Answer 35

vMinimally invasive
vMay take longer than gastrotomy
vSome objects difficult to grasp/too large

Question 36

con for surgery for GIU foreign body

Answer 36

• More invasive