GI disease Flashcards
what are the 2 phases of digestion
luminal
mucosal/membraneous
what is epi
inadequate secretion of pancreatic enzymes
maldigestion
steatorrhoea
what is biliary disease
failure of emulsification
lipase works but unable to solubilise lipids in micelles
maldigestion
what is ileus
inhibition of smooth muscle causing decrease in motility
clinical signs of intestinal disease
diarrhoea
vomiting
abdo pain/discomfort
weight loss
anorexia
flatulence
borborygmi
constipation
tenesmus
melaena or haematochezia
what defines diarrhoea
passing faeces with increased volume and/or frequency
categories of diarrhoea
osmotic - maldigestion, malabsorption
secretory - toxin, infection related
inflammatory - IBD
motility disorder
infectious - bacteria eg, salmonella, viral, parasites
investigation into intestinal disease
signalment
history
PE
haematology/biochemistry - cause/effect
faecal analysis
management of diarrhoea
fluids
electrolytes
control losses - vomiting/regurgitation
analgesia
anti-emetics
gut protectants
Acid base disturbances
can cause metabolic alkalosis/acidosis
SI diarrhoea - metabolic acidosis
severe vomiting - metabolic alkalosis
in all - manage underlying cause and restore renal perfusion
what causes jaundice
hyperbilirubinaemia >50umol/L
what is bilirubin
product of haemoglobin metabolism
haemoglobin > heme>biliverdin>bilirubin
how does bilirubin appear on excretion
urobilin - turns urine yellow
stercobilin - turns faeces brown
haemolytic anaemia causes
acquired - hypophosphatemia, oxidative damage
genetic defects - abyssinian/somali cats have hereditary haemolysis
non-spherocytic in beagles, phosphofructokinase in spaniels
immune mediated
mechanical injury - turbulent blood flow neoplasia
Types of immune mediated haemolytic anaemia
primary - spontaneous, common in spaniels, diagnosis of exclusion
secondary - drugs/toxins, other immune disease, infection, neoplasia
diagnosis of haemolysis (pre-hepatic)
PCV - anaemia - macrocytic, hypochromic regenerative is classic for haemolysis
blood smear - sperocytosis and auto-agglutination
visual inspection
can develop thrombocytopaenia concurrently
hepatic causes of anaemia
infectious hepatic disease
inflammation - cholangiohepatitis
neoplasia - lymphoma, mct, adenocarcinoma
drugs/toxins - paracetamol, nsaids etc
degeneration - amyloidosis, lipidosis,cirrhosis
proximal biliary disease - cholangitis,cholangiohepatitis
diagnosis of hepatic anaemia
biochemistry
- alt - elevation = hepatocellular damage
- ast - liver/muscle, can raise with venipuncture
- alp - concentrated in biliary tree, small elevations significant in cat as short half life
ggt - biliary tree (and other areas) useful in combination with alp
functional tests
- urea - low values support reduced liver function
- ammonia - high as not converted into urea
- albumin - low values support liver disease
- clotting factors - produced by liver
bile acid stim
imaging - ultrasound/ct, fna/biopsy
post-hepatic causes of jaundice
intraluminal obstuction
mural - inflammation/neoplasia
extra-mural - pancreatic disease, duodenal disease, porta-hepatic stricture
CE/history for jaundice
CE
ecchymoses/bruising
perhipheral oedema
cranial abdo pain
neuro deficits - hepatic encephalopathy
low bcs in chronic
ascites
associated signs for regurgitation
dyspnoea
cough
nasal discharge
associated signs for vomiting
hypersalivation
lip-licking
signs of nausea
hypersalivation
lethargy
anorexia
lip smacking
burping
causes of vomiting
vomiting centre - elevated csf pressure through nausea/inflammation
vestibular apparatus - motion sickness/otitis
perhipheral receptors - git, pancreas, liver, mesentary, peritoneum, urinary tract, heart
chemoreceptor trigger zone - drugs, metabolic disorders, toxins
foreign body vomiting
pathophysiology - obstruction increases pressure and dilates/compromises perfusion leading to inflammation and vomiting
diagnosis - plain/contrast radiography, ultrasound, CT and endoscopy
treat by removal
Intussusception
pathophysiology - vigorous contraction forces segment into the adjacent segment’s relaxed lumen
causes - idiopathic, parasitism, masses, fb
diagnosis - ultrasound
treatment - surgery
maropitant
anti-emetic
NK-1 action
affects the vomiting centre, peripheral receptors and CRTZ
97% effective, avoid with obstruction and reduce dose with hepatic disease
Ondansetron
Anti-emetic
5HT3 action
affects the peripheral receptors and CRTZ
avoid with obstructions
Metoclopramide
Anti-emetic
action on D2 receptors affecting the CRTZ
often used as a cri, coordinated gastric motility (prokinetic) reduce dose in hepatic/renal disease
Differentials for chronic intestinal vomiting
Inflammation
neoplasia
most common
Adenocarcinoma causes of vomiting
signs - chronic vomiting and diarrhoea, malaena, haematemesis, weight loss
CE - lymphadenopathy, abdo mass/pain?
Radiography - abdo mass, constricting lesion
ultrasound - intestinal mass, loss of layering, reduction in motility
diagnosis - biopsy, staging with blood loss/fna
treatment - surgery - 75% have mets at diagnosis
lymphoma cause of vomiting
CS - chronic vomiting/diarrhoea, malaena, haematemesis, weight loss
CE - lymphadenopathy, abdo mass/pain
Radiography - abdo mass/constricting lesion
Ultrasound - thickened abdo wall, loss of intestinal layering, reduced motility
Diagnosis - biopsy/FNA
Treatment - surgery/chemotherapy
Prognosis - 4-18m better in cats
Physiology of vomiting
active reflex mediated via the emetic centre, can be stimulated by the chemoreceptor trigger zone, GI tract, cerebral cortex or vestibular system
lots of systems to consider as cause
acute vs chronic vomiting causes
acute - toxic, obstructive, inflammatory, infectious
chronic - chronic inflammation, chronic infection, metabolic/endocrine and neoplastic
physiology of regurgitation
passive expulsion of food from pharynx/oesophagus
consider anatomy, musculature and neurological systems
oesophagus - sphincters
what is dysphagia
failure to prehend/bite and move to swallow food
pain on opening/closing of the jaw
failure of neuromuscular control
obstruction
regurgitation
failure to pass the oesophagus
dilation - megaoesphagus
obstruction
neuromuscular disorder
gastroprotectants
omeprazole - PPI
Misoprostal - prostaglandin analogue - dont use with pregnancy
H2 receptor agonist - cimetidine - reduce acid secretion
sucralfate - binds damaged mucosa
diagnostic testing
imaging - obstructive/anatomical disease
radiography
ultrasound - pocus for free fluid
haematology/biochemistry
specific blood tests
treatment of ingested toxins in stomach
induce emesis withing 2-8h dog and 2-12h cat
apomorphine in dogs
xylazine/medatomidine isnt licensed but may be used in cats
Intestinal transit of toxins
use adsorbents - activated charcoal, binds toxin for excretion but does cause black faeces
Skin exposure of toxins
decontamination of the skin - washing - take care as prolonged washing can wash in some toxins, take care drying as abrasions can allow toxin
inhaled toxins
cannot decontaminate - take care if retrieving
metabolic toxins
prevention of metabolising once in the blood stream
fluid therapy best
lipid infusion for lipid soluble compunds
body system assessment
neuro - seizures, ataxia, sedation
cardiovascular - arrythmias, tachy/bradycardia, hypo/hypertension
GI - V+/D+
renal - azotaemia/inapprorpiate usg
hepatic - jaundice, alt,alp,bile acids
clotting time/anaemia
Ibruprofen/Nsaid toxicity
reduced prostaglandin production
CS - haemorrhagic V+/D+, aki
treatments - H2 blockers - cimetidine
PPI - omeprazole
Prostaglandin analogue - misoprostal
Aspirin toxicity
prostaglandin inhibition plus thromboxane inhibition (platelet function)
CS - thrombocytopathy
Treatment as NSAIDs
Paracetamol toxicity
NAPQI excess de-toxified by glutathione, stores can be exhausted
excess = hepatic cell necrosis, nephrotoxicity
CS - brown MM, jaundice, abdo pain, lethargy, vomiting, AKI, tissue hypoxia
Treatment
- N-acetyl cysteine - glutathione precursor
- H2 receptor agonists
- vit C
- liver, AKI and GI support
chocolate toxicity
methyl-xanthines increasing catecholamine release, increase cAMP and inhibits adenosine receptors
CS - hyperactivity, V+/D+, arrythmias, seizures, coma, death
Treatment - charcoal 4-6 hourly, can need intubation/urinary catheterisation
Xylitol toxicity
mimics glucose but not broken down in the same way
Stimulates insulin release and is hepatotoxic leading to prolonged hypoglycaemia (12-48h) and liver failure in 72h
CS - weakness, collapse, seizures, coma, death, jaundice
treatments - hepato-protectant - sAME, UDA, silybin. Glucose supplementation
Pyrethroid poisoning
found in ant powders/old flea products
cats susceptible
CS - ataxia, tremors, disorientation, seizures, dyspnoea, respiratory arrest, hypersalivation, vomiting
diagnosis on exposure/CS
Treatment - general principles, decontamination, intralipid very good
Cleaning procedures
damage through surface contact
CS - oral pain, dysphagia, regurgitation, vomiting
dont do gastric decontamination
Dilute with oral water etc
Ethylene glycol toxicity
metabolised into glycoaldehyde, glycolic acid and oxalic acid.
Glycoaldehyde - neurotoxic
Glycolic acid - severe acidosis
oxalic acid - calcium oxalate crystals in organs
High mortality
CS - v+, lethargy, ataxia followed by tachyarrythmias, tachypnoea, hypocalcaemia then AKI and death
Treatment - medical ethanol/vodka diluted with saline. Dialysis with referral
Warfarin poisoning
inhibits vit K production which stops clotting factors leading to coagulopathy
Diagnosis - prolonged clotting, haemothorax in large bleeds
Treatment - injectible/oral vit K, fresh frozen plasma for clotting factors
raisin/grape toxicity
substance unknown
leads to AKI
treatment - IVFT
Recreational drug toxicity
Cocaine - hyperactive/hyperthermic/V+/ataxia. General treatment
Marijuana - vomiting, ataxia, depression, coma, incontinence. treated generally, intralipid, catheterisation and anxiolytics
Opiates - depression, lethargy, V+, constipation. Treatment - general, reversal - naloxone
Ketamine - ataxia, hallucinations, aggression, cataplexy - treated with general principles and intubation
Lily toxicity
substance not known
cats very sensitive - AKI
dogs - GI signs
Treat as AKI plus decontamination in case of pollen on feet etc
Onion/garlic/leek/chive toxicity
large quantities for toxicity
sulphur containint - haemolysis/heinz body anaemia
CS - V+/D+, tachycardia, tachypnoea, pale MM
treat - general principles + transfusion
Tremorgenic mycotoxins - fungus
Penitrem A - neurotxic
CS - muscle tremors, hyperaesthesia, seizure, coma, death (rare)
Treatment - general principles, methocarbamol for tremors but is off license (diazepam does not work)
Good prognosis but look bad
signs for FB
history - scavenger, acute severe vomiting, abdominal pain/palpable obstruction
diagnosis - plain/contrast radiography, ultrasound, CT/endoscopy
Treat by removal
Treatment of acute gastritis
time, reduced toxin exposure, fluid therapy
anti-emetics
reduce acid damage - highly digestible, low fat/fibre wet/hypoallergenic
helicobacter chronic gastritis
high prevalence in companion animals
try symptomatic meds/diet first
in man treated with - amoxyclav, clarithromycin and PPIs
what antiemetics are available
maropitant
ondansetron
metoclopramide
what drugs reduced acid secretion
PPIs
H2 agonists
antacids
synthetic prostaglandins
sucralfate
Gastric ulceration
end of chronic gastritis
CS - chronic vomiting, haematemesis, malaena
Bloodwork - evidence of GI bleeding
Ultrasound - loss of wall layering, reduced motility, free fluid with perforation
endoscopy - similar to neoplasia, biopsy for definitive
Treatment - surgical for perforation, medical for chronic gastritis
what is a gastrinoma
rare neuroendocrine tumour of the pancreas secreting gastrin
leads to ulceration/erosion along the GIT
Indications for exploratory laparotomy
if diagnosis can only be made by inspection/palpation
if diagnosis needs cytological/histological or culture for diagnosis
Therapeutic indications for ex lap
haemorrhage control
correction of contamination/infection
elimination of pain cause
removal of mass
removal of visceral obstruction
removal of traumatised organs
relief of dystocia
removal of abnormal fluid accumulation
supportive care
common mistake during exlap
failure to make a large enough incision
failure to explore the entire abdominal cavity
failure to take appropriate biopsies
failure to be prepared for the likely diagnosis or diagnoses
failure to approach the intra-operative findings in a logical fashion
what are the 5 regions to check
cranial quadrant
intestinal tract
right paravertebral
left paravertebral
caudal
what fixes the duodenum in place
dueodeno-coelic ligament
what does the duodenal manouvere allow visualisation of
caudal pole of right kidney and right ovarian pedicle
what does the colonic manouvere allow visualisation of
left kidney and left ovarian pedicle
what layer of the linea alba is crucial to close
rectus sheath
what suture pattern is best for the linear alba
continuous to spread tension
why do you have to take care an oesophagostomy tube doesnt sit in the stomach
it allows acid reflux
clinical signs of oesophageal FB
retching
regurgitation
vomiting??
ptyalism
anorexia
restlessness
cervical pain
what drugs can be used to reduce chance of oesophageal stricture after FB removal
H2 antagonists
PPI
sucralfate
analgesia
feed soft food
indications for gastric surgery
placement of gastric feed tube
gastrotomy for FB
gastropexy to stop volvulus
correct GDV
pyloroplasty for outflow disease
partial gastrectomy for tumour resection
Enterotomy for FB removal EXAM
Orthogonal xrays needed for locations
proximal to obstruction is likely to be distended and distal empty
incise through unaffected bowel and milk out the proximal distension
close with single layer - simple continuous, interrupted or inverting. use non-cutting needle and drape omentalise
Problems occuring with linear FB
string/wool anchored somewhere proximal
concertinas the bowel and tries to cut through the mesenteric border - can perforate in multiple locations
must free proximal attachment before removal
points of care for enterectomy
clamps on bowel remaining must be atraumatic
others can be traumatic
ligate mesenteric vessels
cut on diagonal towards mesentery to maintain blood supply
end to end anastomosis with simple continuous
close mesentery
indications for large intestine surgery
colopexy
colotomy
colectomy
subtotal colectomy
colonic torsions
small bowel torsion
differences between cat and dog pancreas
dog pancreatic duct small/absent cat is present
dog accessory pancreatic duct is large in cats it is absent in 80%
where do you biopsy the pancreas
tip of the left limb as most avascular
what does the liver do
metabolic processes
digestion of; fat/triglycerides, protein, carbohydrate/glycogen/cholesterol/vits/mins
waste management
protein metabolism
acute diarrhoea causes
diet - food changes, allergies, intolerance, scavenging. food poisoning/toxins
drugs - antimicrobials/chemo
infections - parvovirus, corona virus, adenovirus, rotavirus. Bacteria - salmonella, campylobacter, e.coli, clostridial species
parasites - helminths, protozoa - giardia/tritrichomonas
Parvovirus (cpv-2)
very stable in environment, faecal-oral
CS- V+, D+(haemorrhagic/foetid with mucosal sloughing), dehydration, depression, anorexia, sepsis, ileus
Diagnosis - PCR - snap okay send off better. faecal analysis. haematology/biochemistry
Treatment - fluids, electrolytes, antibiotics - amoxy-clav, anti-emetics, pro-motility (metaclopramide), ant-acids
prevention - vaccination, cleaning/disinfection
what drug can be used both pro-motility and anti-emetic
metaclopramide
haemorrhagic gastroenteritis
idiopathic mostly
CS - vomiting +/-blood, foetid diarrhoea, depression, anorexia, clinical dehydration, high PCV, tp lost in GI
Treatment - fluids, colloids/plasma/whole blood
Anti-microbials - amoxy-clav, metronidazole
Feline panleukopaenia
feline parvo - treated the same
vaccinate in early outbreaks for protection
coronavirus
dog - young/highly contagious, mild villus destruction with enterocytes at tips. If severe give supportive therapy
cat - as with dog but links with FIP
campylobacter
normally commensal
young/immunocompromised causes acute enterocolitis
cs- D++, V+, straining, fever, abdo pain
diagnosis - faecal stain/culture, PCR
treatment - underlying disease if present
salmonella
similar to campylobacter but risk to immunocompromised owners (more so fed raw)
can get - transient diarrhoes, acute gastritis, carrier or bacteraemia
treat if sepsis/shock on culture
negative indicator - hypoglycaemia, temp over 40 degrees and degenerate left shift
clostridial enteritis
normal flora - diarrhoea due to endotoxin production
dont overtreat
metronidazole first choice
very resistant in environment
signs of ascarids
puppies/kittens
failure to gain weight
pot belly
v+, small bowel d+
obstruction of git
respiratory disease with migration
signs of hookworms
diarrhoea
weight loss
anaemia
interdigital dermatitis, perineal irritation
gut adsorbants
kaolin oral suspension good
pro-kinetics
metaclopramide - upper GIT
erythromycin - gastric emptying
ranitidine - anti-cholinesterase
lidocaine - si motility and analgesic
dehydration
cs - skin tent, tacky MM, sunken eyes
= fluid deficit
fluid deficitxbodyweight = litres deficit
what is your starting fluid rate for a dehydrated patient
deficit/24h plus maintenance
fluid care for animals with cancer
weight decreasing, measure regularly to readjust
fluid care for DCM heart failure
with D+/V+
do not relieve full deficit EVER
keep slightly dehydrated to reduce strain on heart
signs of hypovolaemia
increased CRT
pale MM
cold
increased HR
weak pulses
increased RR
signs of sirs/sepsis
CRT decreased
reg/congested MM
pyrexia
increased HR
poor/bounding pulses
increased RR
common pancreatic disease
acute pancreatitis - inflammation, sudden onset with little/no permanent change
chronic pancreatitis - continuing inflammatory disease with irreversible morphological changes - fibrosis/atrophy. can lead to permenant impairment of function
clinical signs of pancreatitis
lethargy/weakness
anorexia
V+/D+
abdominal pain
cranial abdo mass
mild ascites
dehydration
fever
jaundice
anaemia
lab findings for pancreatitis
haematology - anaemia, haemoconcentration, leukocytosis
biochemistry - azotaemia, increased ALP, hyperbilirubinaemia, hyper/hypo glycaemia, hypoalbuminaemia, hypertriglyercidaemia, hypercholesterolaemia
electrolytes - hypokalaemia, hypochloraemia, hyponatraemia, hypocalcaemia
imaging for pancreatitis
radiography - rarely useful, can see displacement of abdominal organs
abdominal ultrasound - enlargement, localised effusion, decreased echogenicity (pancreatic necrosis), hyperechogenicity (pancreatic fibrosis in chronic), pancreatic duct dilation
pancreatitis treatment
underlying cause
analgesia
antiemetics
antibiotics - in infectious
feeding - high carb, low fat
enteral feeding if anorexic
complications of pancreatitis treatment
pancreatic pseudocyst - similar signs to pancreatitis, significance unclear
pancreatic abscess - bacterial infection rarely present, cranial abdominal mass, avoid surgery unless enlarging and not responding to drugs
long term pancreatitis management
avoid high fat - fat restricted diet
oral pancreatic enzymes supplements
recurring episodes - prednisolone
pancreatic neoplasia
adenomas - singular, benign, incidental, can obstruct duct/cause EPI
Adenocarcinoma - more common, originate in ducts or acinar tissue, necrosis can cause inflammation
CS- V+/D+, weight loss, anorexia
imaging - radiography- mass, splenic displacement. Ultrasonography - soft tissue near pancreas, sample peritoneal effusion
diagnosis - ex-lap/PM - biopsy
Treatment - prognosis grave, resection can be attempted
gross appearance of pancreatic nodular hyperplasia
small nodules through exocrine portion
no capsule
usually incidental
pancreatitis gross appearance
oedematous tissue
soft
swollen
fibrinous adhesions
serosanguinous free fluid
pseudocysts
haemorrhages
fat necrosis
diets appropriate for pancreatitis
Oral
Dogs - use easily digestible diet, moderate/low fat content
Cats - high protein, fat restriction unnecessary
refeeding protocol
if anorexic for >3-5 days when refeeding feed only 1/3rd of RER on day 1
increase in small meals up to RER at day 3 if tolerated
decreased risk of metabolic complications
where are the anal sacs located
4 and 8 oclock between internal and external sphincter muscles
considerations of anal/rectal issues
infection risk - large clip, evacuate rectum, pack rectum, dont use enemas - more likely to contaminate, anti-biotics with cover for anaerobes (metronidazole)
very vascular - high chance of haemorrhage
faecal incontinence is a risk around the external anal sphincter
cause of anal gland blockage
change in faecal consistency effecting emptying eg diarrhoea, diet, tapeworm, oestrus
CS - scooting
easily diagnosed on palpation
treatment - manual expression, can require flushing
indications for anal sacculectomy
recurrent impaction
neoplasia
on occasion part of peri-anal fistula treatment
how can you make anal sacculectomy easier
inject resin into the gland via the duct to make the border clear for resection - inflation of foley catheter in sac also works
complications of anal sacculectomy
draining sinus
infection
dehiscence
tenesmus
faecal incontinence
anal furunculosis
deep ulcerating tracts - needs major treatment (euthanasia is an option)
associated with increased apocrine glands in perineum
treatment - dampen the immune system - prednisolone and hypoallergenic diet - very limited use
often need surgical resection
perianal adenoma
common in male dog
hairless anal ring - tail base/prepuce/ventrum
biopsy
slow growing, rare in castrated and resolve with castration
0.5-3cm can ulcerate
anal adenocarcinoma
malignant lesion of perianal sebaceous gland
very infiltrative/adherent and rapidly growing
aggressive surgical removal required
poor prognosis
anal sac adenocarcinoma
female >10
hard pea sized lumps in sac walls
secretes PTH like substance and causes hypercalcaemia (leads to PUPD, depression, weakness, weight loss)
diagnosis - palpation, biochemical findings, radiography/CT
Treat hypercalcaemia
excise mass, metastectomy and chemotherapy
rectal prolapse
endoparasites/enteris associated
incomplete = mucosa only
complete = all wall layer
oedematous, excoriated and bleeding tissues possible
straining in history
Lavage, lubricate and reduce
amputate is traumatised
colopexy if recurrent
rectal stricture
secondary to proctatitis/anal sacculitis, FBs or surgical complication
Dx - digital rectal exam, radiography/colonoscopy
biopsy to differentiate from neoplasia
give corticosteroids
rectal polyps
benign, male/female, mean age 7
CS - blood/mucus in faeces, may prolapse
treatment - surgical removal
rectal adenocarcinoma
infiltrative/ulcerative/proliferative invading rectal wall
CS - tenesmus, dyschezia, weight loss, lethargy as they advance
Dx- palpation, radiography, ultrasound, endoscopy
Tx - colorectal resection/anastomosis
can become incontinent - discuss
atresia ani
uncommon - associated with recto-vaginal/rectal-urethral fistulae, can have secondary megacolon
CS - tenesmus, perineal bulging
Dx - radiography
Tx - surgical creation of an anus
reasons for underweight patients
underlying condition increasing requirement - neoplasia, GI dysfunction, inflammation
different nutrient requirements - pancreatitis/portosystemic shunts
disease stage - high/low protein depending
RER calculation
70(BWkg)x power 0.75
or (30xBW) +70 (for 2-45kg)
diet requirements
calorie dense - not chicken
palatable
as normal as possible - if raw…cook it!
complete
tactics to encourage eating
warming
hand feeding
bowl type
texture
covered area
owner visits
interventions for hyporexia/anorexia
monitor closely for 1-2 days
2-4 day intervention required - feeding tube if undergoing procedure
>5 days must intervene
nasooesophageal tube placement
feed in ventromedially
drop intubeze in nose first
crunching = bad
sterile lube
x-ray for placement
cant go home
PEG tube
placed using endoscope
placed via surgical incision through wall
wait 24h for adhesion
what should you not use as a post op diet
chicken/rice
causes of malnutrition
diet - inappropriate eg wrong age, not enough for age/activity level
not wanting to eat - pain, stress, nausea, pyrexia, appetite suppressants
physically cannot eat - dental disease, oral/pharyngeal masses, mandibular/maxillary abnormalities, congenital defects, neuromuscular disorders
masticatory muscle myositis
immune mediated inflammatory condition
acute - inflamed masticatory muscles, struggles to open jae
chronic - fibrosis/atrophy, cannot open mouth, anorexia/weight loss
Dx - circulating autoantibodies against 2m fibres. haematology/biochemistry
treatment - best in acute phase - immunosupressive prednisolone. chronic - poor prognosis
cricopharyngeal achalasia
uncommon - dysphagia/regurgitation
Dx - fluoroscopy - cricopharyngeal muscles dont relax
Tx - surgery
malutilisation
calories not absorbed correctly
protein losing nephropathies, diabetes mellitus, liver disease
increased nutrient demand - neoplasia, hyperthyroidism, infection, parasites
usually systemically unwell
what is hyporexia
not eating well enough for normal maintainence
things to look for with appetite loss
drooling/pyrexia/pain
consider haematology/biochemistry/urinalysis
anti emetic trial for nausea
common causes - renal/hepatic disease, inflammatory/infectious causes, neoplasia
things to look for with reluctance to eat
changes around feeding - bowl location/other animals etc
home changes
common causes - nausea, pain, stressful events, change of diet
mechanical inability to eat
check can open/close mouth normally
pain in neck/mouth/limbs
video eating to bring in
may need sedation to assess
common causes - dental disease, gingivostomatitis, oral/pharyngeal/oesophageal massess
Hepatic lipidosis risk
particularly anorexia in obese animals with fat mobilisation
CS - hepatomegaly, jaundice, lethargy, V+/D+, ileus, hypersalivation, pallor, neck ventroflexion(cat), coagulopathies
Dx - biochem (alp,alt,ast), haematology (nonregenerative anaemia etc) can have low coag as low vit K. Hepatomegaly
Tx - ivft, supplementation of K+, phosphate, b12. feed slowly. antiemetics
Refeeding syndrome
fed too much after prolonged anorexia with electrolyte depletion. hypokalaemia - co transport with glucose and depleted levels
/hypophosphataemia
CS - seen in 5d of refeeding - cervical ventroflexion, muscle weakness, acute RBC lysis, respiratory failure
Tx - slow refeeding, check electolyte levels and supplement
prevent - slow refeeding protocol
septic peritonitis causes
bacteraemia
GI perforation
penetrating injury
iatrogenic (swabs)
ascending UTI
aseptic peritonitis causes
Inflammatory
Splenic abscess
Hepatitis
Nephritis
Cholangitis
Pancreatic enzymes
Bile
haemoabdomen
uroabdomen
stomach acid
diagnosis of peritonitis
POCUS for free fluid (shapes with angles)
tap - septic/not
diagnostic peritoneal lavage
treatment of peritonitis
source control
antibiotics- if septic YES do not wait at all and survival chance rapidly declines - metroidazole/amoxicillin. aseptic - NO
what is an acute abdomen
acute onset abdominal pain
often present collapsed/V+/shock
areas that can cause acute abdomen
spine - pain in all abdominal area
ventral - splenic rupture/torsion, SI - rupture/torsion/entrapment, gravity dependent - peritonitis/haemo/uroabdomen, space occupying
dorsal - kidney, radiation from stomach, spinal, spleen
cranial - liver, pancreas, spleen, stomach
caudal - colon, prostate, bladder, uterus
diagnosis for acute abdomen
radiography - obstructive disease
labwork - haem/biochem, BP, lactate, electrolytes, acid/base
metabolic acidosis findings
low pH
lactic acid related
breath off CO2 so normal-low
reduced bicarbonate
give hartmanns as alkalising
metabolic alkalosis findings
pathognomic for pyloric obstruction as acid not entering duodenum
high pH
normal/high CO2 as breath slows
high bicarbonate as not being used by acid
give saline as dissociates into NaOH and HCL - resting pH 5.5
clinical signs of ascites
abdominal distension
discomfort
dyspnoea
lethargy
can report - weight gain, difficulty rising
diagnosis of ascites
history
clinical exam
ballottement - fluid wave
ultrasound
protein poor transudate ascites
pathophysiology - altered fluid dynamics, hypoalbuminaemia, decreased plasma colloid oncotic pressure
DDx - protein losing nephropathy/enteropathy, hepatic failure
Dx - biochemistry, unrinalysis, ultrasound
protein rich transudate ascites
Pathophysiology - increased hydrostatic pressure in blood/lymphatics, protein leaks from capillaries, TP most important, over time inflammation and increased TNCC
DDx - cardiovascular disease, chronic liver disease, neoplasia, thrombosis
Dx - ultrasound, radiography, biochemistry
septic exudate ascites
DDx - penetrating wound, surgical complication, rupture of infected leison, bacteraemia
Dx - abdominocentesis, appearance, cytology, C&S, lactate/glucose
CS - sick and painful, normally require surgery
non-septic exudate ascites
DDx - neoplasia, uroperitoneum, bile peritonitis, FIP
Dx - abdomincentesis, fluid appearance, cytology, fluid analysis (high urea, creatinine/potassium if uroperitoneum)
biochemistry, ultrasound
Lymphatic effusion
rare - obstruction/destruction of lymphatics
DDx- cardiac disease, hepatic disease, neoplasia, steatitis (fat inflammation)
Dx - appearance (milky), cytology (many small lymphocytes, fluid analysis, ultrasound, biochemistry
haemorrhagic effusion
DDx - surgical/non-surgical trauam, haemostatic defects, neoplasia
Dx - pcv/tp, platelet presence, cytology, ultrasound
what is dyschezia
difficult/painful defecation
what is tenesmus
excessive straining to pass stools
causes of dyschezia
colonic impaction
perineal hernia/rectal diverticulum
rectal stricture
anal neoplasia
severe prosatomegaly
obstipation (chronic constipation)
causes of tenesmus
top - colitis
bone ingestion
rectal/anal tumours
post op (perineal surgery)
prostatomegaly
colitis signs
colon not absorbing water/ overproduction of mucous
CS - tenesmus, soft stools, mucus in stool, fresh blood, generally well
Treat - metranidazole/sulphursalazine, high fibre feed
constipation
uncommon - normally actually tenesmus/dyschezia
Feline idiopathic megacolon EXAM
Presentation - recurrent constipation, colon dilation, hypomotility of the colon
Causes - mostly idiopathic can be pelvic/sacral spinal deformity
Leads to permanent loss of colonic structure/function
>1.5x length of 7th lumbar vertebra = mega on radiography
can feel
Treatment - laxatives (lactulose), enemas (soapy water), high fibre feed
surgery - subtotal colonectomy - try to maintain ileocaecal junction
pre-op antibiotics, NO preop enema
slow to heal with risk of dehiscence
basic dietary requirements
protein - growth/repair
fat - energy and fat soluble vitamin(ADEK) carrier
carbohydrate - energy
water - fluid balance
vitamins/minerals for everything
how is best to increase energy in feed
increase fat content - 8.5kcal/g
how does neutering affect weight gain
adjusts fat storage
energy levels drop
safe weightloss targets
1%/week in cats
1-2%/week in dogs
use interim targets if requiring >15% body weight loss
what is in a weight loss diet
low fat, low carb, high fibre, high protein in dog
high fibre - slows digestion but increases faeces volume
low fat, low carb, high protein in cats - hepatic lipidosis prone if too restricted
causes of weight gain
non pathological - exercise, growth, pregnancy
pathological - neoplasia, hyperplasia, inflammation, cysts/abscesses, organomegaly, fluid retention
causes of increased appetite
systemic disease - normal calorific demand - hyperadrenocorticism
systemic disease - high caloric demand - acromegaly, insulinoma
iatrogenic - glucocorticoids/phenobarbitone.mirtazapine
behavioral/psychological/neurological
acromegaly
increased growth hormone
Cats - associated with functional pituitary adenoma, mostly middle age/older males
dogs - unneutered females, elevated progesterone
CS - cutaneous thickening, macroglossia, increased dental spacing, prognathism, diabetes mellitus signs but weight gain not loss
Dx - clinical signs, elevated GH and IGF-1
Treatment - surgery - dogs (OVH+mamary strip) cats(hypophysectomy). Radiotherapy, drugs (dopaminergic/somatostain analogues)
insulinomas
functional neuroendocrine tumours - produce excessive insulin leading to low blood glucose
clinical signs - increased appetite, weight gain, weakness, ataxia, collapse, seizures
Dx - hypoglycaemia resolving with glucose administration (exclude other causes) ultrasound for mass/mets a lot spread before identified. CT best
Tx - surgery - excisional reduces clinical signs with mets, nodulectomy/partial pancreatectomy. Medical - diet (small frequent meals), prednisolon, octreotide (inhibits insulin production), diazoxide (decreases insulin release). Chemotherapy - streptoxotocin
staging of insulinomas
1 - only pancreatic
2 - regional lymph node
3 - distant mets
hypothyroidism types
primary - idiopathic gland atrophy/immune mediated lymphocytic thyroiditis
secondary - space occupying mass, has neuro signs
congenital - abnormal thyroid development, dyshormonogenesis or abnormal TSH production
iatrogenic - excessive hyperthyroid treatment in cats
hypothyroid signs/signalment
dogs - middle aged/older, large breed
cats - following treatment for hyperthyroid
CS - dull, lethargic, exercise intolerent, hypothermia, dry coat, increased shedding - symmetrical alopecia of trunk/thighs/tail/neck, slow regrowth, tragic expression, hypotension, bradycardia, repro issues, perhipheral neuropathies
diagnosis - routine bloods suggestive. definitive - conpatible signs + low total t4/free T4 AND normal-high TSH
Treatment - levothyroxine + monitoring
what test is used for hypothyrodism confirmation
TSH with free or total T4
aims of hernia surgery
return content to normal location
close neck of sac
obliterate redundant tissue
why should monofilament be used to close hernia
avoid sinus formation
what care do you need to take with hernia closure
tensionless closure
omentum -
eliminate dead space
drains if necessary
umbilical hernias
normally congenital
lined by peritoneal sac
soft/painless
can have V+/abdo pain with strangulation
normally contain fat/omentum and normally reducible or can fix at neutering
dont breed
surgery - elliptical incision, undermine stump/remove fat, close in straight line
causes of incisional herniation
incorrect technique from surgeon
incorrect material/suture pattern
entrapped fat
infection
steroid therapy
poor post op care
CS - oedema, inflammation, serosanguinous fluid, soft painless swelling, palpable defect, exposed viscera
Treatment - repair asap, can eviscerate so open and repair entire wound make sure external rectus abdominis (strongest holding layer)
inguinal hernia
inguinal ring abnormality/trauma
association with obesity/pregnancy
neutering recommended
small breed <2 male/middle aged female
non-painful unless incarcerated contents
scrotal hernia
common with large inguinal rings/open castrations (guinea pigs)
diaphragmatic hernia
common following RTA, can be congenital
tear allows abdo contents into thorax
CS - pale/cyanotic, tachy/dyspnoeic, tachycardic, occasionally arrhythmic, hydrothorax. Chronic can have GI signs - exercise intolerance, dyspnoea, V+, weight loss
Dx - radiography - loss of diaphragmic line. ultrasonography
Treatment - oxygen, IVFT, warming, higher mortality if surgery under 24h post accident. but acute gastric distension (operate asap. prophylactic antibiotics
perineal hernias
uncommon, bulging perineum. associated with faecal tenesmus/dysuria
cause - weakening of pelvic diaphragm, hormonal influence, tenesmus, congential, colitis/prostatomegaly
pelvic/peritoneal fat herniation through pelvic diaphragm
reducible swelling, can asses on rectal palpation
ultrasouns/contrast urethrography will highlight
Tx - herniorrhaphy - close gap in diaphragm
hiatal hernias
brachycephalic - congenital defect
CS - regurgitation, hypersalivation, visceral discomfort, thin
Dx - radiography, flouroscopy (best) endoscopy
Tx - antacid, sucralfate, prokinetics, antibiotics. surgery - ventral midline coeliotomy, reduce hernia at oesophageal hiatus, pexy oesophagus to diaphragm and stomach to body wall
peritoneopericardial diaphragmatic hernia - uncommon
congenital communication between diaphragm and pericardium
CS - GI signs - V+/D+/anorexia, weight loss, wheezing, dyspnoea
radiography - enlarged cardiac silhouette, dorsal displacement of trachea, gas in pericardium. ultrasound. contrast radiography
Surgery - ventral midline coeliotomy, reduce viscera, suture diaphragm
what determines if blood in the abdomen
PCV of abdominal fluid compared to that of blood - will be lower
if ~ same as blood - acute haemoabdomen
fluid higher pcv than blood - semi-acute haemoabdomen
pcv of fluid lower than blood - chronic haemoabdomen (cancer/haemangiosarcoma)
neoplastic haemoabdomen
acute/chronic
how bad - BP/lactate
fluids/transfusion - auto-transfusion, pRBC (with plasma best). whole blood best
Treatment - surgery, chemo, euthanasia
traumatic haemoabdomen
rta
acute
whole blood/pRBC/plasma
transaxemic acid - antifibronilytic maintains clotting
dont operate!
coagulopathic haemoabdomen
iatrogenic - warfarin poisoning
bp/lactate
fluids/transfusion - fresh frozen plasma then pRBC, auto transfusion good but need plasma
uroabdomen
assessment - urinary catheter, 3 way tap and saline/air syringes - make bubbles instilling the two which can be seen on scan
tap free fluid - urea (free moving), creatinine (relevant if >2x blood value), potassium(relevant is >1.4x blood)
Hyperkalaemia worry - bradycardia, atrial standstill(no P wave), elecrolytes on blood gas - control source and give hartmanns
aerophagia
swallowed air
what can gas distension of the stomach cause
GDV
momentum for 180-360 degree twist, most turn clockwise
causes caudal vena cava compression, gastric vessel compression/necrosis
splenic engorgement/twists
pathophysiology of GDV
associated with eating too fast, especially after eating
associated with deep chest eg setter/GSD, doberman, dachshunds
not fully understood
obstructive shock treatment
tube - oro/nasogastric tube, trochar if tube placement not appropriate
oxygen therapy (hyperoxygenation good)
fluid therapy
GDV surgery
anaesthetic precautions - cardiovascularly compromised so avoid alpha 2, use methadone for pain, coinduce with midazolam and propofol
continuous monitoring of BP
ventilation perfusion mismatch with diaphragmatic compression
care with re-perfusion injury acidosis/hyperkalaemia
techniques - incisional (easiest ) incise pyloric serosa and deep into abdominal wall and stitch together
decompress fully before rotating
care of gastric arteries
any signs of twisting remove spleen, do not untwist
GDV post op care
regular checks
lidocaine
monitoring electrolytes
ecg for 24-48h
oxygen
major differentials for chronic enteropathy
food responsive
dysbiosis
antibiotic responsive
steroid responsive
non-responsive
PLE
EPI
neoplasia
most common chronic enteropathy
food responsive
food responsive enteropathy
adverse reaction to food
V+/D+/pruritis possible
food trial excluding antigen - should see results in under 3 weeks (different to skin disease). diet reintroduction should relapse
Dx - food trial, food specific serum immunoglobulin (commercially available, not accurate). endoscopic sensitivity testing - direct application to mucosa, IgE mediated hypersensitivity, biopsies from reactive sites
dysbiosis
major complication of ce - bacterial overgrowth common decreased gastric acid, increased SI substrates (epi/malabsorption), partial obstructions, anatomic disorders, hypothyroidism. primary condition in susceptible breeds (GSD iga deficiency)
CS - small bowel D+, weight loss, failure to thrive, V+, borborygmi, appetite changes
Dx - history/determine underlying cause, faecal microbiome analysis. serum folate/B12, coalbumin levels. Breath hydrogen testing (difficult), circulating bile acids
Treatment - oxytetracycline/tylosin/metronidazole (4-6 weeks)
ancillary approaches preferred - diet, pre/probiotics, coalbumin supplements
steroid responsive enteropathy
perisistent GI signs with cellular infiltrate
cs - chronic diarrhoea, more common >12 months, weight loss, abdo discomfort, V+(cats)
diagnosis - imaging, biopsies,
work out which cellular infiltrate and treat appropriately
lymphoplasmacytic gastroenteritis
mucosal changes
eosinophilic enteritis
severe signs - GI haemorrhage, bowel perforation, focal mass lesions
difficult to control
feline triaditis complex
CE/IBD. pancreatitis/cholangiohepatitis
diagnosis - biopsy, blood tests, radiography, ultrasound
treat depending on CS - manipulate diet, anti-parasitics (fenbendazole), vitamins, immunosuppression
PLE
low albumin and low globulin
