GI Medicine Flashcards
What are the clinical signs of oropharyngeal disease?
Drooling saliva +/- blood (ptyalism vs pseudoptyalism)
Halitosis
Dysphagia +/- odynophagia
How do we investigate oral disease?
Physical examination (consider feasibility of intubation) Radiographs Minimum database FNA and/or biopsy Special tests
What can cause oropharyngeal disease?
Oropharyngeal foreign bodies
Oral ulceration/burns
Oropharyngeal inflammatory disease
How do we treat oropharyngeal disease?
Depends on underlying cause Neoplasia = surgery (/cryosurgery, radiation, chemotherapy) Foreign body = remove Trauma = wound management/surgery Inflammation = anti-inflammatories Bacterial infection = antibiotics
What nursing considerations should we have for oral disease?
Analgesia (NSAIDs, opioids)
Nutrition - oral feeding (warm/wet/soft) / requirement for bypass/tube feeding
Barrier nursing for infectious aetiologies
Why is poor oral/dental hygiene bad?
Partially causative e.g. feline gingivostomatitis
Source of ongoing bacteria/oropharyngeal inflammation/infection
Describe regurgitation.
Passive return of food Hallmark of oesophageal disease Immediate or delayed - undigested food +/- mucus/saliva Neutral pH Solid or liquid Fresh blood if ulcerated
What secondary problems can we see with regurgitation?
Malnutrition, dehydration
Anorexia or perceived polyphagia
Reflux pharyngitis/rhinitis (nasal discharge)
Aspiration pneumonia (cough, dyspnoea, pyrexia)
Swallowing pain (odynophagia)
How do we investigate oesophageal disease?
Physical examination
Chest X-rays - conscious!
Lab tests - haematology/serum biochemistry
+/- oesophagoscopy
What are the possible pathophysiologies of oesophageal disease?
Megaoesophagus
Oesophagitis
Oesophageal obstruction (complete/partial) - intraluminal/intramural/extraluminal
Describe megaoesophagus.
Oesophageal dilation/dysfunction Generalised (idiopathic, myasthenia gravis) Focal dilation (e.g. vascular ring anomaly)
How do we treat megaoesophagus?
Idiopathic = no cure
Myasthenia gravis = neostigmine, pyridostigmine
Vascular ring anomaly = surgery
Nursing care/management to minimise impact of oesophageal dysfunction
What nursing considerations should we have for megaoesophagus patients?
Postural feeding
Stairs/work surface
+/- support, e.g. Bailey chair
Slurry vs textured food
What complications can occur for megaoesophagus patients?
Aspiration pneumonia - tachypnoea, pyrexia, lethargy, inappetence
Treat with IV antibiotics
Body weight and condition, adjust feeding as necessary
Describe oesophagitis.
Oesophageal inflammation caused by ingestion (caustics, hot liquids/foods, foreign bodies, irritants e.g. doxycycline) / gastro-oesophageal reflux / persistent vomiting
May cause oesophageal strictures
What are the clinical signs of oesophagitis?
Regurgitation Hypersalivation Anorexia Pain Weight loss
How do we manage oesophagitis?
Oesophageal rest (+/- gastrotomy feeding, soft/bland food small + frequent)
Analgesia
Liquid antacid gels/coating agents
Acid blockers (omeprazole)
Drugs to reduce further reflux (metoclopramide, cisapride)
What are the causes of gastro-oesophageal reflux?
Reflux of gastric acid/enzymes, inflammation
During anaesthesia
Persistent vomiting
Hiatal hernia
GERD (‘heartburn’) - spontaneous reflux (obesity, BOAS)
Describe oesophageal foreign bodies.
E.g. bones, sticks, needles, fish-hooks, rawhide chews
Can lodge anywhere - obstruction/regurgitation, may be able to drink
Raw/bone feeding = risk
Remove endoscopically/fluoroscopically +/- surgery
What is an oesophageal stricture and how do we treat it?
Fibrosis after severe ulceration of mucosa
Treatment = dilation with balloon catheter
Describe vomiting.
A complex, coordinated reflex reaction
Integrated sequence of overlapping events
Does not involve gastric contraction
What are the 4 stages of vomiting?
Stage 1 = prodromal phase
Stage 2 = retching
Stage 3 = expulsion
Stage 4 = relaxation
Describe the prodromal phase of vomiting.
Nausea
Restlessness, agitation
Hypersalivation
Gulping, lip-licking/smacking
Describe the retching stage of vomiting.
Inhibition of saliva
Simultaneous, uncoordinated, spasmodic contractions of respiratory muscles
Duodenal retroperistalsis
Mixing of gastric contents
Describe the expulsion stage of vomiting.
Pyloric contraction, fundic relaxation
Relaxation of proximal stomach and lower oesophageal sphincter
Initially high tone in upper oesophageal sphincter
Protection of airway (inhibition of breathing, coordinated closure of glottis and nasopharynx)
Abdominal contraction and descent of diaphragm (stomach squeezed and vomitus forced up, oesophageal retroperistalsis, reduced upper oesophageal sphincter tone)
Describe the relaxation stage of vomiting.
Muscles - abdominal, diaphragmatic, respiratory
Glottis, nasopharynx
Return of breathing
Describe small intestinal diarrhoea.
Large volume, watery
Normal frequency
Often normal colour
+/- malaena
Describe large intestinal diarrhoea.
Small volume Increased urgency and frequency Tenesmus, dyschezia \+/- mucus \+/- blood
Define -gastritis, -enteritis and -colitis.
- gastritis = stomach
- enteritis = small intestine
- colitis = large intestine
What are the main phone triage questions we should ask for a vomiting/diarrhoea patient?
Vomit - productive/non-productive Frequency - fluid losses Foreign material Haematemesis/melaena? Diarrhoea - small/large intestinal
What other questions should we ask in a phone triage for a v/d patient?
Pre-existing medical disease/medications (e.g. NSAIDs) Pre-existing gastrointestinal disease Worming history (especially puppies/kittens) Recent dietary change? Known scavenger? Clinical demeanour Appetite, drinking Other systemic signs
When should we advise consultation for a v/d patient?
Unproductive vomiting Large fluid volumes lost Haematemesis/melaena Suspicion for foreign material ingestion Inappetent/hypodipsic Other systemic signs Puppy/kitten Any other concerns
Give some examples of causes of non-fatal, often trivial acute v/d.
Dietary indiscretion
Parasitism (e.g. roundworms, whipworms, protozoal)
Enteric infection
Adverse drug event
Give some examples of causes of severe and potentially life-threatening v/d.
Pathogenic enteric infections (parvovirus, bacterial) Acute Haemorrhagic Diarrhoea Syndrome Acute pancreatitis Surgical disease Intoxications
Give some examples of causes of surgical disease v/d.
Intussusception (has underlying cause) Gastric dilation and volvulus Incarceration Stricture/partial obstruction Foreign body
What are the possible consequences of vomiting and/or diarrhoea?
Dehydration
Hypovolaemia
Acid-base disturbances (loss of electrolytes)
Aspiration pneumonia (especially if sedated/neuromuscular/upper airway incompetency)
What are the diagnostic tests for acute gastroenteritis?
History, physical examination
Bloods - haem/biochem/electrolytes
Faecal - infectious disease testing (pooled sample/swab or faecal sample)
Imaging
+/- response to symptomatic treatment/surgical management
How can we maintain hydration in a v/d patient?
IV - Hartmann’s (+KCl)
Oral rehydration solutions
What dietary advice can we give for a vomiting patient?
Rest the gut - free access to water
So starve for 24-36hrs
Re-introduce bland diet, little and often
Then transition to normal diet over 2-5 days
What dietary advice can we give for a diarrhoea patient?
Feed through diarrhoea
Reduces potential of sepsis
Cosmetic problem in dogs, but usually concurrent vomiting
What supportive/symptomatic management can we offer v/d patients?
Antiemetics - exclude obstruction first
Antispasmodics
Anti-diarrhoeals - cosmetic only
How do we treat acute v/d?
Anthelmintics (if puppy/kitten or not recently wormed)
Antibiotics rarely indicated - consider if haemorrhagic diarrhoea +/- pyrexic
Pre/probiotics
How do we use NSAIDs in v/d patients?
Absolutely contraindicated!
Pre-existing use - withhold for duration
Prostaglandins required for maintenance of GI mucosal integrity/renal blood flow in hypovolaemic states
When should we consider an infectious cause of acute gastroenteritis?
Puppy/kitten Unvaccinated animals Haemorrhagic diarrhoea Pyrexia Raw-fed patient Barrier nurse/isolate until diagnosis confirmed