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GI disease Flashcards

1
Q

Categories of things that can cause excess salivation?

A
  1. Physiologic
  2. Toxins/local irritants
  3. Medications
  4. Oropharynggeal disease
  5. Salivary gland disorders
  6. Infectious disease
  7. Pseudoptyalism
  8. Metabolic
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2
Q

Physiologic causes of salivation

A
  1. Imminent feeding

2. Anticipation of medications

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3
Q

Toxins or local irritants causing ptyalism

A
  1. Organophosphates
  2. Cleaning solutions, disinfectants, caustics
  3. Insect or spider bites
  4. Skin secretions of some toads
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4
Q

Medication causes of ptyalism

A
  1. Antibiotics
  2. Anthelmintics
  3. Others
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5
Q

Oropharyngeal diseases that can cause ptyalism

A
  1. Inflammation or oral cavity including tongue (feline stomatitis/gingivitis)
  2. Foreign bodies (look under base of tongue)
  3. Neoplasms (Squamous cell carcinoma, malignant melanoma, acanthomatous ameloblastoma, fibrosarcoma, osteosarcoma)
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6
Q

Salivary gland diseases that can lead to ptyalism

A
  1. Parotid hyperplasia

2. Inflammation (sialoadenitis)

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7
Q

Infectious diseases that can lead to ptyalism

A
  1. Rabies (ALWAYS inquire about vaccination and travel history)
  2. Pseudorabies (uncommon)
  3. Botulism (may be accompanied by signs of lower motor neuron disease)
  4. Tetanus (may be accompanied by muscle spasms/tetany)
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8
Q

Pseudoptyalism causes

A
  1. Swallowing disorders
  2. Anatomical abnormalities of the oral cavity, pharynx, or esophagus that limit or prevent swallowing
  3. Foreign bodies in the oral cavity, pharynx, or esophagus that limit or prevent swallowing
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9
Q

Metabolic disorders that can cause ptyalism

A
  1. Any disorder causing nausea (GI or non-GI origin)
  2. Portosystemic shunts (especially cats)
  3. Hypoparathyroidism
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10
Q

General diagnostic approach to problem of ptyalism

A
  1. Obtain complete history and do thorough physical exam focusing on oral cavity, pharynx, and esophagus. May need sedation or anesthesia. If suspecting a local disease, that may take preference over other diagnostic interventions. Can help to watch the patient swallow or eat.
  2. If no apparent cause, rule out metabolic causes with CBC, CHemistry, and urinalysis. In cats, consider testing for FIV and FeLV if status isn’t known.
  3. If necessary, pre- and post-prandial bile acids or ammonia testing to rule out PSS/impaired hepatic function
  4. Consider chest rads or contrast studies like an esophagram or swallowing under fluoroscopy to rule out disorders of swallowing or esophageal disease. Can do early if history or physical exam suggests a swallowing disorder, esophageal disease, or foreign bodies, or history isn’t clear regarding these possibilities.
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11
Q

Diagnostic approach to problem of difficulty eating

A
  1. Complete PE and history, focusing on oral cavity (including teeth), pharynx, esophagus, and musculoskeletal system of head. May be important to observe attempts to eat.
  2. Perform ancillary diagnostics as dictated (neurologic exam; radiographs with dynamic contrast including fluoroscopy potentially to document swallowing disorders; biopsy of apparent lesions, masticatory muscle biopsy (usually after type 2M antibody serology); culture e.g. for herpes or calicivirus; FeLV/FIV serology; CBC/chemistry/urinalysis)
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12
Q

What are features that suggest vomiting?***

A
  • Prodromal signs (restlessness, lip licking, hypersalivation, retching, frequent swallowing) that precede ejection of stomach contents.
  • Should be accompanied by strong and forceful abdominal contractions.
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13
Q

What can elicit vomiting?

A
  • Stimulation of central and/or peripheral chemoreceptors
  • Distension of an abdominal viscus or capsule
  • Neurologic inputs (vestibular disease)
  • A disease that causes vomiting may do so through a variety of mechanisms operating jointly.
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14
Q

Features that suggest regurgitation***

A
  • Absence of abdominal effort
  • Lack of prodromal signs of retching and nausea (remember that inability to swallow saliva could be misinterpreted as hypersalivation often seen with nausea)
  • Appearance of undigested food that may have a tubular form
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15
Q

Diagnostic approach to regurgitation

A
  1. Obtain complete history and perform thorough physical exam focusing on oral cavity, pharynx, esophagus, and thoracic cavity. If you cannot differentiate regurgitation from vomiting, consider a thoracic radiography to evaluate esophagus. If that is unclear, you could consider contrast studies.
  2. If there is evidence of megaesophagus, consider:
    - CBC/chemistry/urinalysis to rule out systemic disorders
    - Acetylcholine-receptor antibody titer (AKA “myasthenia gravis titer”) and if positive, perform thoracic radiographs to rule out thymoma
    - Neurolog examination
    - Thyroid and adrenal gland function tests
    - Others as indicated
  3. If no evidence of megaesophagus but there is high clinical suspicion for regurgitation/esophageal disease, consider contrast esophagram and/or esophagoscopy or fluoroscopic gastrogram to assess pyloric function.
  4. If evidence of aspiration pneumonia, see more.
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16
Q

What disease should you consider in a patient with radiographic evidence of aspiration pneumonia and no obvious predisposing factors?

A
  • Esophageal disease that could require esophagograms or esophagoscopy
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17
Q

What to consider diagnostically if dog with megaesophagus or suspicion of megaesophagus also has evidence of aspiration pneumonia?

A
  • Bronchoalveolar lavage for cytology, culture/sensitivity (best approach to alveolar disease, but may have limited availability, and requires general anesthesia)
  • Tracheal wash for cytology, culture/sensitivity
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18
Q

Diagnosis and treatment of Physaloptera

A

Diagnosis: Observe parasite during gastroscopy

Treatment: pyrantel pamoate, fenbendazole, or ivermectin

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19
Q

Diagnosis and treatment of Ollulanis

A

Diagnosis: observe parasites in vomit

Treatment: fenbendazole

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20
Q

How can small intestinal disease lead to vomiting?

A
  • Virtually any small intestinal disease may cause vomiting (acute or chronic) that is mediated by either peripheral (e.g. inflammation, distension) and/or central events (chemoreceptor trigger zone stimulation).
  • Duodenal inflammation, distention, and osmoreceptor stimulation are particularly potent stimulators of vomiting; the duodenum has sometimes been referred to as the organ of vomiting.
  • Vomiting may be the only clinical sign seen in patients with inflammatory bowel diseases; especially true with cats
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21
Q

How can large intestinal disease lead to vomiting?

A
  • Some dogs and cats may exhibit vomiting 2° to large bowel disease, especially those that cause, or are associated with, acute distention of the large bowel (e.g. obstructions, enemas) or those associated with inflammation
22
Q

Correlation between laboratory abnormalities and pancreatitis

A
  • Can be poor (especially amylase and lipase activity in the serum)
  • Absence of expected abnormalities DOES NOT DOES NOT DOES NOT rule out pancreatitis.
  • Even more true for cats.
23
Q

Diagnostic approach to the problem of vomiting

A
  1. Obtain complete history and PE including rectal examination.
  2. From history and physical, determine whether in depth diagnostic evaluation is needed - not all vomiting patients need diagnostic intervention.
  3. If not needed, pursue supportive therapy
  4. If in-depth diagnostics are required, perform diagnostics as the case requires to rule-out non-GI causes.
  5. Once non-GI causes have been excluded, consideration may be given to endoscopic examination and biopsy of the stomach and small intestine, or plain/contrast radigoraphic studies and AUS if not already done.
  6. For animals with the problem of chronic vomiting, if the animal is otherwise healthy (good appetite, maintaining weight) and lab values is normal, consideration can be given to dietary trials or manipulations before extensive diagnostic evaluation (e.g. gastrointestinal biopsy).
  7. If additional diagnostics are needed for chronically vomiting patient, possibilities to consider include imaging of the abdomen/GIT (ultrasound, contrast studies, CT), measurement of serum folate, cobalamin, pancreatic lipase and trypsin-like immunoreactivity (GI panel) to get hints to structural SI disease, measurement of serum gastrin concentration (gastrinoma, uncommon) and endoscopic or surgical biopsies of the GIT.
24
Q

Indications for possible in-depth diagnostic assessment

A
  • Depression
  • Anorexia
  • Weakness
  • Marked dehydration
  • Abnormalities in respiratory rate or character
  • Mm abnormalities (congestion, pallor, prolonged or extremely rapid refill)
  • Tachycardia/poor pulse quality/arrhythmias
  • Fever
  • Melena/hematemesis
  • Abdominal organomegaly or masses
  • Pain
  • Effusions/edema
  • Chronicity
  • Lack of response to supportive treatment, or progression/worsening of clinical signs in the face of such therapy
25
Q

Supportive therapy for GIT disease

A
  • NPO for 12-36 hours if deemed clinically appropriate (use clinical judgment to determine whether to withhold water or not; most animals with self-limiting GIT disease can tolerate water if ingested as frequent small volumes)
  • Parenteral fluids as needed
  • Gastric protectants (sucralfate; proton-pump inhibitors* - he’s not a fan)
  • Antiemetics (not commonly needed)
  • Antibiotics (not indicated unless evidence of mucosal disruption
  • Monitor
26
Q

Initial In-depth diagnostics for vomiting patients

A
  • Database: CBC, biochemical profile (including amylase and lipase), urinalysis, T4 (in cats)
  • Also consider abdominal radiographs or ultrasound
  • Specific tests for infectious disease (e.g. stool ELISA for parvo)
  • Heartworm tests for animals in endemic areas
  • Basal cortisol and ACTH stim testing
  • Initially done to rule out non-GI causes of vomiting
27
Q

What diagnostics to consider if non-GI causes of vomiting have been excluded?

A
  • Endoscopic exam and biopsy of stomach and SI
  • Plain/contrast x-ray studies and abdominal ultrasound if not done
  • Patients with focal or sometimes diffuse thickening of the GIT or GI masses are candidates for needle aspiration
  • Enlarged lymph nodes can also be aspirated under ultrasound guidance
  • These can be considered early if hematemesis is observed, there is a reason to suspect ulcerative gastric disease, or there are indications from PE (painful or distended abdomen, palpation of a mass, etc.)
  • Some animals are candidates for exploratory laparotomy and surgically obtained biopsies
  • History, PE, and lab findings may influence this
28
Q

When to do an empiric food trial?

A
  • For animals with chronic vomiting, if the animal is otherwise healthy (good appetite, maintaining weight) with normal laboratory database
  • Some clients insist on empiric therapy before extensive diagnostics
  • Anthelmintic treatment for oddball parasite can be a consideration for empiric therapy
29
Q

Characteristics of small bowel diarrhea

A
  • Melena may be present
  • Normal to increased stool volume
  • Frequency of defecation is normal to mildly increased
  • Urgency is usually absent
  • Weight loss if common with chronicity
  • Vomiting is common
  • Stool quality may have fat or undigested food
30
Q

Characteristics of large bowel disease

A
  • Tenesmus
  • Mucus in stool
  • Hematocehzia
  • Stool volume is normal to decreased
  • Frequency of defecation is usually increased
  • Urgency is often present
  • Weight loss is uncommon but can be seen
  • Vomiting is occasional
  • Stool quality won’t have any undigested food or fat
31
Q

General clinical signs of dogs with chronic, non-infectious inflammatory bowel diseases

A
  • Chronic diarrhea
  • Weight loss
  • Vomiting
  • Some degree of appetite loss
  • Some patients with inflammatory bowel disease have no primary GI signs and so may be examined only for consequences of the mucosal disease (e.g. hypoalbuminemia/ascites)
32
Q

Non-infectious causes of large bowel diarrhea

A
  • Dietary indiscretion*
  • Idiopathic inflammatory colitis
  • Neoplasia
  • Irritable bowel syndrome
33
Q

1st step of diagnostic approach to diarrhea

A
  1. Obtain a complete history and perform a thorough PE including a rectal. Pay particular attention to palpation of the abdomen to assess for the presence of masses, organomegaly, thickness of intestinal loops, and pain.
34
Q

2nd step of diagnostic approach to diarrhea

A
  1. Determine if further steps are warranted. Fecal examinations, or empiric anthelmintics, are warranted on VIRTUALLY ALL of these patients. Fecal examinations could include floats, direct smears, wet mounts, or ELISA tests for infectious disease (parvo, Giardia, Cryptosporidia), screen cats of unknown backgrounds (FeLV/FIV). Reasons to pursue in depth diagnostics in a patient with diarrhea include all of the same listed for vomiting.
35
Q

Reasons to pursue in-depth diagnostics for diarrhea

A
  • Same as for vomiting
36
Q

3rd step of diagnostic approach to diarrhea

A
  1. If indicated, consider the following laboratory tests to exclude non-GI disease: CBC, biochemical profile, urinalysis, basal cortisol, and serum thyroid hormone in cats. Follow up with additional tests as needed (e.g. ACTH stimulation if there is evidence of hypoadrenocorticism).
37
Q

4th step of diagnostic approach to diarrhea

A
  1. If non-GI illness and parasitic/infectious disease has ben excluded on the basis of laboratory test results, the next steps taken depend on whether one is dealing with a small or large bowel diarrhea (it is assumed for these patients that intestinal parasites have been excluded either by multiple fecal examinations or by lack of response to anthelmintic treatment or other therapy.
38
Q

4th step of diagnostic approach to diarrhea for small bowel

A
  1. Rule out EPI by performing serum TLI. Reasonable to also get concentrations of folate and cobalamin, and pancreatic lipase.
  2. Once EPI has been ruled out, it is common, if additional diagnostics are to be performed, to image the abdomen (ultrasound, plain and contrast radiographs) as a prelude to either empiric therapy (antibiotics, diet trial) or intestinal biopsy by endoscopy or surgery. There are advantages and disadvantages to each biopsy approach.
  3. Abdominal radiographs may occasionally reveal patterns suggestive of a partial obstruction (e.g. due to foreign body, intussusception, masses)
  4. Abdominal ultrasound may be useful for detecting increases in intestinal wall thickness, mesenteric lymph node enlargement, masses, and intussusceptions, but false negatives are relatively common. Aspiration of lymph nodes and masses may be aided with ultrasound; ultrasound may also help determine if one is dealing with focal or diffuse disease, which may influence biopsy approach (endoscopic vs surgical)
  5. Antimicrobial therapy and dietary trials as a “diagnosis by response to therapy” are now commonly done as initial approaches to patients with chronic diarrhea if there are no clinical signs or laboratory abnormalities indicative of serious disease, for patients in which a diagnosis has not been achieved, or for those not eligible for in-depth diagnostics. Endoscopic or surgical biopsies of the intestinal tract are increasingly used as a last diagnostic intervention in patients with chronic diarrhea when other diagnostic tests, or treatment approaches, have failed to identify/resolve the diarrhea.
  6. Glucocorticoids are sometimes used empirically in the treatment of dogs or cats with chronic diarrhea. The timing of administration should be considered carefully before giving, and pros/cons of empiric glucocorticoid therapy should be discussed with owners beforehand.
39
Q

Advantages and disadvantages of endoscopy for biopsy

A
  • Limited access to GIT (esophagus, stomach, proximal SI, occasionally ileum, large intestine)
  • Superficial biopsies may miss deeper abnormalities, availability may be limited; less expensive, and considered non-invasive, and will often establish a diagnosis of many GI diseases
40
Q

Advantages and disadvantages of surgery for biopsy

A
  • Relatively unlimited access to GIT but limited assessment of the mucosa; full thickness biopsies considered superior to endoscopic biopsies, can be accomplished in most practices
  • More invasive
  • Usually more expensive than endoscopic examination and biopsy
41
Q

General diagnostic approach to large bowel diarrhea

A
  • Less clear cut in GENERAL due to role of diet and colonic bacterial flora
    1. Rule out parasitic disease, or simply evaluate response to treatment with antibiotics and/or anthelmintics. In whipworm endemic areas, administer anthelmintic with whipworm spectrum of activity. Consider wet mount to look for flagellated organisms. Consider empiric therapy with antibiotics such as metronidazole
    2. Consider a dietary trial; if the diet has been poor in fiber, add fiber to diet. If diet has abundant fiber, consider switch to a low residue diet; consider novel protein/novel carbohydrate diet if others don’t work.
    3. Culture a stool sample for Salmonella, Campylobacter, Yersinia
    4. Endoscopically examine and biopsy the large intestine
42
Q

What is tenesmus?

A
  • Persistent or prolonged straining that is ineffectual and may be painful (dyschezia is painful defecation)
43
Q

Constipation

A
  • Infrequent or difficult defecation
44
Q

Obstipation

A
  • Intractable constipation

- Usually implies loss of colonic motility function

45
Q

Diagnostic approach to tenesmus

A
  1. Obtain a thorough history (attempt to distinguish straining to urinate from straining to defecate) and perform a complete physical. Rectal examination is absolutely critical on all dogs.
  2. If tenesmus is localized to the GI tract but the cause is not apparent or suggested, consider similar diagnostics as available for large bowel diarrhea.
46
Q

Hematochezia

A
  • Presence of streaks of fresh blood on the stool
47
Q

Dfdx for Hematochezia (broad categories)

A
  • Usually reflects disease of mid to distal large bowel, rectum, or anal sacs; a rectal exam can be diagnostic often
  • Can also be seen with pancreatitis
  • Coagulopathies may result in hematochezia and should be considered when this problem is seen in absence of other signs of large bowel disease (e.g. tenesmus, mucus in stool)
48
Q

Melena

A
  • Dark, tarry stools that result from the presence of blood that has been altered by acid. Rarely observed in cats
49
Q

GI vs non-GI bleeding locations for melena

A
  1. Bleeding of primary GI origin: oral cavity or oropharynx (swallowed blood); esophagus (uncommon); stomach (ulcers or neoplasia); proximal small intestine (ulcers, neoplasms, hookworm infection)
    - Also described in dogs with hypoadrenocorticism
  2. Non-GI origin, from swallowing blood: Nasal cavity bleeding (epistaxis) or hemoptysis
  3. Coagulopathies may result in bleeding anywhere along the GIT. In his experience, thrombocytopenia is more commonly associated with GI bleeding than are other coagulopathies, but keep in mind that thrombocytopenia is also the most commonly encountered coagulopathy in SA practice.
50
Q

Diagnostic approach for melena or hematochezia

A
  1. Obtain thorough history and perform complete physical exam to try and localize source of bleeding
  2. If melena is from GI origin, perform fecal, then CBC, biochemical profile, and urinalysis. Consider coag tests (PT,PTT). If not obvious, consider endoscopy, abdominal ultrasound, plain/contrast radiographs. If bleeding is from a focal source and severe, may need exploratory surgery for definitive diagnosis and therapy
  3. If hematochezia, rule out large bowel disease or coagulation disorders

GI and Liver (3 decks)

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