Gastroenterology Pt. 1 Flashcards by Mark Sunarich

examples of non-specific GI signs

¡ Usually accompany more specific signs
¡ Occasionally the only signs

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

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

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

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vomiting vs regurgitation: basic difference / way to differentiate

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

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vomiting vs regurgitation: abdominal effort

Regurgitation: none
vomiting: marked

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vomiting vs regurgitation: prodromal nausea

Regurgitation: none
vomiting: present

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vomiting vs regurgitation: character of ejected food

Regurgitation: undigested food (typically)
vomiting: usually digested

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vomiting vs regurgitation: timing of food ejected

Regurgitation: variable
vomiting: variable

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vomiting vs regurgitation: Swallow attempts of a single bolus

regurgitation: usually single
vomiting: single

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vomiting vs regurgitation: ability to drink

regurgitation: variable
vomiting: normal

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vomiting vs regurgitation: pain on swalling

regurgitation: possible
vomiting: absent

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vomiting vs regurgitation: associated signs

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

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what type of problem may accompany esophogeal motility problem

dysphagia (difficulty swallowing)

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what often accompanies vomiting in cats

-retching

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

¡ 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

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if in doubt about regurgitation vs vomiting…

¡ If in doubt – thoracic radiographs

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gastrointestinal vs extra-gastro-intestinal causes of vomiting

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

differential diagnoses for acute vomiting

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

how do we diagnose acute gastritis

Self-limiting vomiting
Diagnosis of exclusion
Occasionally endoscopic biopsy

6 causes of acute vomiting

-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

6 causes of acute regurgitation

-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

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

-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

what does conservative management of acute vomiting entail?

¡ 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

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

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

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

Factors promoting workup and/or hospitalization for acute vomiting

¡ 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

lab workup for vomiting? purpose of this?

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

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

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

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

¡ Common and useful in work-up of acute vomiting

purpose of barium with radiology for acute vomiting

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

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

- 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”

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

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

when is ultrasound useful in a vomiting case

¡ 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

Gastric foreign body management options

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

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

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

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

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

pros and cons for endoscopy for gastric foreign body management

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

con for surgery for GIU foreign body

* More invasive