Internal medicine (gastroenterology) Flashcards
what are the clinical signs of oropharyngeal/oesophageal disease?
dysphagia
saliva drooling
halitosis
odynophagia (painful swallowing)
regurgitation
what is odynophagia?
painful swallowing
what are the ways in which dysphagia can be described?
difficulty lapping or forming bolus
excessive jaw/head motion
dropping food from mouth
saliva drooling
persistent/ineffective swallowing
nasal discharge
gagging/coughing
what are the two reason dysphagia can occur?
functional - abnormal neuromuscular activity
morphological - structural abnormalities
what are some functional causes of neuromuscular dysphagia?
cricopharyngeal achalasia
myasthenia gravis
brainstem disease
peripheral neuropathy
polymyopathy
what could cause morphological dysphagia?
oropharyngeal inflammation/trauma
foreign bodies
neoplasia
congenital deformities
what is inflammation of the oral mucosa called?
stomatitis
what is inflammation of the lips called?
cheilitis
what is inflammation of the tongue called?
glossitis
what is inflammation of the gums called?
gingitvitis
what is inflammation of the pharynx called?
pharyngitis
what is inflammation of the tonsils called?
tonsilitis
what are some congenital morphological causes of dysphagia?
lip-fold deformities
cleft palate
malocclusion
craniomandibular osteopathy
how would regurgitation be described?
a passive event of undigested food covered in mucus/saliva being brought up the oesophagus (immediately after eating)
what is pseudoptyalism?
failure to swallow normal volume of saliva
what is ptyalism?
increased saliva production
what needs to be found out to define whether the animal is vomiting or regurgitation food?
what is brought up
when it is brought up (relation to feeding)
vomiting signs (active process)
concurrent disease
illness duration
what contrast can be used for GI tract?
barium mixed with food
iodine contrast (if perforation suspected)
what are some specialist test that can be used for oesophageal disease?
anti-ACh receptor antibody
2-M antibodies
ACTH stimulation test
what is the anti-ACh receptor antibody test used for?
primary oesophageal disease
what are 2-M antibody tests used for?
see if there are antibodies targeting the muscle of mastication (these are specific to there)
what is the definition of megaoesophagus?
oesophageal dilation with functional paralysis
what are the finding on radiograph of a patient with megaoesophagus?
uniformly dilated with gas/fluid filling
ventrally displaced trachea
possible secondary aspiration pneumonia
why is fluoroscopy occasional essential to diagnosing megaoesophagus?
can determine dysmotility of oesophagus
how can idiopathic megaoesophagus be treated?
feeding from a height (upright)
textured food/balls or slurry
metoclopramide (improve motility)
what is the prognosis for patients with idiopathic megaoesophagus?
guarded - often get aspiration pneumonia
what are possible causes of oesophagitis?
ingestion of caustics/irritants
foreign bodies
acute/persistent vomiting
gastric reflux
what are the clinical signs of oesophagitis?
anorexia
dysphagia
odynophagia
regurgitation
hypersalivation
how is oesophagitis treated?
(rest oesophagus)
frequent small soft feeds
liquid antacids
local anaesthesia
how can sucralfate aid oesophagitis treatment?
gastric protectant - coats mucosa of oesophagus
what is the aetiology of oesophageal strictures?
fibrosis after ulceration due to… foreign bodies, caustic agents, gastric reflux, drugs, severe oesophagitis
how can oesophageal strictures be treated?
dilation - bouginage or balloon
what is the disadvantage of using bougienage to dilate oesophageal strictures?
increased risk of perforations compared to balloon dilation
what is the most common place for oesophageal foreign bodies?
lower oesophageal sphincter (also heart base and thoracic inlet)
how are oesophageal foreign bodies treated?
removal via endoscopy (surgery is a last resort)
what should always be done after removal of an oesophageal foreign body?
radiograph (check for pneumomediastinum) - this can indicate a tear
what is primary vomiting due to?
underlying gastric disease
what is secondary vomiting due to?
non-GI disease
what is the events that happen after the vomiting centre is triggered to cause vomiting?
pylorus is contracted
stomach and lower oesophageal sphincter relaxes
abdominal muscles contract
glottis is closed
upper oesophageal sphincter opens
antiperastalsis propels food towards the mouth
what can switch on the vomiting centre of the brain?
duodenum
stomach
pharynx
vestibular system
chemoreceptor trigger zone
what are some possible secondary causes of vomiting?
infections, pyometra, renal failure, drugs, CNS disease, motion sickness, vestibular disease, neoplasia…
what can cause chronic vomiting?
intestinal/peritoneal disease
primary gastric disease
diffuse GI disease involving stomach
what are some causes of chronic vomiting secondary to intestinal/peritoneal disease?
inflammatory bowel disease
intestinal neoplasia
small intestinal obstruction
pancreatitis
peritonitis
what primary gastric diseases can cause chronic vomiting?
chronic gastritis
gastric retention disorders
gastric ulcers
gastric neoplasia
what diffuse GI diseases involving the stomach can cause chronic vomiting?
inflammatory bowel disease
alimentary lymphoma
what are the three basic models of the pathophysiology of gastric disease?
gastric outflow obstruction
gastroparesis
disruption of mucosal barrier
what diagnostic clinical pathological tests can be done for vomiting animals?
electrolytes
haematology
bile acid stimulation test
ACTH stimulation
urinalysis
pancreatic lipase
what are some possible causes of chronic gastritis?
dietary intolerance
chronic gastric parasites
hairballs
immune mediated
what are the clinical signs of chronic gastritis?
intermittent chronic vomiting
periodic early morning vomit with bile
poor appetite
gastric bleeding
what are the possible treatment options for chronic gastritis?
removal of aetiological agent
diet - trials, multiple small meals…
acid blockers
corticosteroids
what is the best diet for chronic gastritis cases?
hydrolysed protein diet
when does bilious vomiting usually occur?
vomiting occurs overnight/morning in dogs fed once a day (especially in the morning)
what is the presumed aetiology of bilious vomiting?
abnormal internal motility allowing bile reflux into the stomach
how can bilious vomiting be treated?
feed more often (later in the day)
prokinetics - ranitidine…
what is a gastric retention disorder?
food is retained in the stomach for >8 hours causing delayed vomiting of food (way longer than it should be retained)
what are the possible causes of gastric retention disorders?
anatomical obstruction
functional disorders - motility, inflammatory disease…
what are the possible outflow obstructions to the stomach causing gastric retention disorders?
pyloric stenosis
neoplasia/polyps
foreign bodies
chronic hypertrophic pyloric gastropathy
what prokinetics can be used to treat gastric retention due to a functional problem?
metoclopramide
ranitidine
erythromycin
how does metoclopramide work as a prokinetic for gastric retention?
stimulates normal gastric peristalsis
how does ranitidine work as a prokinetic for gastric retention?
stimulates peristalsis and hydrogen antagonist
how does haematemesis look if blood has been in then stomach for a while?
coffee grounds
what are some possible causes of haematemesis?
generalised bleeding
swallowed blood (oropharyngeal, nasal…)
severe gastritis
gastric ulcer
gastric neoplasia
duodenal disease
what are the clinical signs of gastric ulcers?
haematemesis
melaena
anaemia
weight loss
pain
peritonitis
what posture in associated with abdominal pain?
prayer posture
what are the possible causes of gastric ulcers?
drugs - NSAIDs, corticosteroids
head and spinal injuries
gastritis
liver/kidney disease
bile reflux
mastocytosis
helicobacter
what species of helicobacter causes gastric ulcers?
H. pylori
how are gastric ulcers treated?
sucralfate
acid blockers - antacids, H2 antagonists, proton pump inhibitors
what are some H2 antagonists used to treat gastric ulcers?
cimetidine
ranitidine
nizatidine
what proton pump inhibitor is used for gastric ulcer treatment?
omeprazole
what should not be given with omeprazole to treat gastric ulcers? and why?
NSAIDs as they can worsen intestinal ulceration
what is used to treat helicobacter?
triple therapy (two antibiotic plus an acid blocker)
what is an example of a triple therapy used to treat helicobacter?
amoxicillin, metronidazole, clarithromycin (triple antibiotics)
amoxicillin, metronidazole, omeprazole (2 antibiotics and acid blocker)
what are the majority of the neoplasms found in the stomach of dogs?
adenocarcinomas
where do gastric adenocarcinomas often metastasise to?
local lymph nodes and liver
when would you suspect a gastric adenocarcinoma?
older animals with chronic vomiting, anorexia, weight loss, haematemesis, anaemia and saliva drooling
what is the prognosis for gastric adenocarcinomas?
hopeless (surgical resection is rarely curative and often painful)
what is chronic diarrhoea?
diarrhoea that has been present for more than 2 weeks
what are the steps for approaching diarrhoea cases?
history/physical exam
symptomatic therapy
laboratory investigations
diagnostic imaging
GI biopsy
therapeutic trials
what are the main alimentary disease differentials diagnoses for diarrhoea?
adverse food reactions
inflammatory bowel disease
antibiotic responsive diarrhoea
lymphangiectasia
lymphoma/tumour
infectious diarrhoea
partial obstructions
what is lymphangiectasia?
effects the lymphatic system within the small intestine causing a blockage leading to dilation of the vessels
what is a linear foreign body?
long thin foreign body such as string/wire (can wrap around tongue or other structure)
what should be checked for in the oral cavity of diarrhoea cases?
CRT
gum colour
hydration (wet gums)
linear foreign bodies
what is haematochezia?
fresh blood in faeces
what are the features of small intestinal diarrhoea?
increased volume
colour change
normal/increased frequency
(weight loss, flatulence, borborygmi, halitosis - all evidence of malabsorption)
why is an increased volume of faeces seen with small intestinal diarrhoea?
small intestine involved with digestion/absorption so damage to this means food isn’t being digested so maintains water in the large intestine (they have malabsorption)
what are the features of large intestinal diarrhoea?
decreased volume
increased frequency
urgency/tenesmus
mucus/haematochezia
dyschezia
(can vary in consistency)
(less weight loss)
what is melaena?
digested blood in faeces (before the small intestines)
how does melaena appear?
dark tar colour
where can diarrhoea most commonly be located to?
large intestine
is fibre supplementation used for small or large intestinal diarrhoeas?
large intestine
is sulfasalzine used for small or large intestinal diarrhoea?
large (only gets activated in the large intestine)
if used for three consecutive days, what does fenbendazole treat?
Giardia (protozoal cause of diarrhoea)
what are the three most common parasites causing diarrhoea in dogs/cats?
Giardia
Cryptosporidia
Tritrichomonas foetus (cats)
what are the most common bacteria causing diarrhoea in dogs/cats?
salmonella
campylobacter
what are the typical cats effected by Tritrichomonas fetus?
young cats
pedigree
cats in colonies
does Tritrichomonas fetus produce large or small intestinal diarrhoea?
large intestinal (small intestinal much more common in cats so if you see signs of LI this is a top differential)
what test can be ran to diagnose hyperthyroidism?
total thyroxine
what test can be run to diagnose hypoadrenocorticism?
ACTH stimulation or basal cortisol
what test is used for diagnosing exocrine pancreatic insufficiency?
trypsin like immunoreactivity
what test can be run to diagnose malabsorption?
folate and cobalamin
where is folate absorbed?
proximal small intestine
where is cobalamin absorbed?
distal small intestine
what can you tell about the outcome of a case if a hypocobalaminaemia is present?
this is a negative prognostic indicator (survival is worse)
what are the two ways to get an intestinal biopsy?
endoscopy
surgical (coeliotomy)
why is surgical (coeliotomy) biopsy better in cats with chronic diarrhoea?
often have other systems (liver and pancreas) effected with inflammation and disease
what will be seen in cases of lymphangiectasia on intestinal biopsy?
lacteal dilation
what should you ask an owner to keep a diary of in chronic diarrhoea cases?
frequency of diarrhoea
other signs (vomiting, pain…)
appetite and demeanour
compliance with treatment
what is constipation?
difficult, incomplete or infrequent evacuation of dry hardened faeces from the bowels
what are some possible aetiologies of constipation?
dietary
neuromuscular (idiopathic megacolon)
environmental (obesity, inactivity…)
colonic obstruction (stricture, pelvic trauma…)
electrolyte imbalance (dehydration, hypokalaemia…)
drug-induced
what are some treatment options for constipation?
remove causative agent
oral laxative (lactulose)
enema
oral polyethylene glycol
gentle manual evacuation
surgery
dietary management
what is a possible oral laxative for constipation treatment?
lactulose
how much of the pancreas is exocrine tissue?
98%
what are the exocrine cells of the pancreas called?
acinar cells
what does the exocrine pancreas produce?
digestive enzymes
intrinsic factor
bicarbonate
what is the function of intrinsic factor?
it binds to cobalamin to protect it through the small intestine and then allow it to be absorbed
what are the two main diseases effecting the pancreas?
pancreatitis
exocrine pancreatic insufficiency
what is the cause of acute pancreatitis?
inappropriate activation of digestive enzymes
what is often the enzyme that drives pancreatitis?
trypsin (activates other enzymes)
what are some possible predisposing factors for pancreatitis?
breed (spaniels/terrier)
gender (female>male)
obesity
drugs
concurrent disease
dietary factors
what is the cause of most pancreatitis?
idiopathic
what are some diseases associated with feline pancreatitis?
cholangitis
inflammatory bowel disease
hepatic lipidosis
diabetes mellitus
what factors of a diet are associated with acute pancreatitis?
high dietary fat
hyperlipidaemia - obesity, diabete…
bin raiding, table scrap…
what are the clinical signs of acute pancreatitis in dogs?
dehydration
anorexia
vomiting
weakness
abdominal pain (prayer position)
diarrhoea
jaundice
what are the clinical signs of acute pancreatitis in cats?
lethargy
anorexia
vomiting
abdominal pain
diarrhoea
what results on haematology/biochemistry suggests acute pancreatitis?
increased white blood cells
increased glucose/decreased calcium
increased liver enzymes
jaundice (increased bilirubin)
what pancreatic enzyme tests are available for acute pancreatitis?
total amylase and lipase
pancreatic lipase
will total amylase/lipase increase or decrease with acute pancreatitis?
increase
what is the advantage of the pancreatic lipase test?
less affected by azotaemia
SNAP test available
what is needed for a definitive diagnosis of pancreatitis?
pancreatic biopsy
what is all of the treatment of pancreatitis based on?
supportive therapy (no cure for it)
what treatment options are available for acute pancreatitis?
nutritional support
pancreatic enzymes
fluid therapy
analgesia
antiemetics
what are the steps of dietary therapy for acute pancreatitis cases?
initial therapy - 3-7 days
interim diet - 3-28 days
long-term diet - 3 weeks onwards
what is usually needed for the initial dietary therapy for acute pancreatitis (3-7 days)?
feeding tube (often anorexic and not wanting to feed on their own)
what are the types of feeding tubes available?
enterostomy tube
nasooesophageal tube
oesophagostomy tube
gastrostomy tube
what is fed in the interim diet therapy for acute pancreatitis patients? (3-28 days)
small amounts of water
low fat diet
small frequent meals
pancreatic enzymes
what is the issue sometimes seen with pancreatic enzyme supplementation?
sometimes stops the patient wanting to eat
what analgesic drugs should be avoided in patients with acute pancreatitis?
NSAIDs
what are some good analgesic options for acute pancreatitis?
buprenorphine
paracetamol
tramadol
gabapentin
what are the two main anti-emetics considered for acute pancreatitis cases?
maropitant (easier to administer)
metoclopramide
what is the aetiology of exocrine pancreatic insufficiency?
pancreatic acinar atrophy (most common)
pancreatic hypoplasia
chronic pancreatitis
what are the clinical signs of exocrine pancreatic insufficiency?
faecal changes
appetite changes
vomiting
poor coat quality
what faecal changes are seen with exocrine pancreatic insufficiency?
large volume
foul smelling
greasy (steatorrhoea)
putty-like to overt diarrhoea
what appetite changes can be seen with exocrine pancreatic insufficiency?
polyphagia - increased
coprophagia
pica - depraved appetite (eating weird things)
what is the best ways to diagnose exocrine pancreatic insufficiency (EPI)?
trypsin like immunoreactivity
are you looking for increased or decreased levels when carrying out a trypsin like immunoreactivity test for EPI?
decreased
how can exocrine pancreatic insufficiency treated?
pancreatic enzymes - powder, enteric coated granules, fresh-frozen pancreas
dietary management - highly digestible diet (2x maintenance)
cobalamin supplementation
why do dogs with EPI need cobalamin supplementation?
pancreas isn’t producing intrinsic factor
what is a poor prognostic indicator of EPI outcome?
low cobalamin (if you need to supplement them)
what is a possible complication of EPI?
bacterial overgrowth - food not absorbed so there is more substrate for bacteria to grow
is EPI more common in dogs or cats?
cats
what are the functions of the liver?
metabolism (protein, fat…)
storage
protein synthesis
bile production
detoxification…
what is icterus also known as?
jaundice
what is jaundice?
build up of bilirubin
what is pre-hepatic jaundice due to?
haemolysis
what is hepatic jaundice due to?
hepatic dysfunction
intrahepatic cholestasis
what causes post-hepatic jaundice?
extra-hepatic cholestasis
what clinical sign can be used to differentiate hepatic and post-hepatic jaundice from pre-hepatic jaundice?
mucous membranes will be pink/yellow in hepatic or post-hepatic jaundice
with pre-hepatic it will be yellow
what metabolic dysfunctions can be seen with liver disease?
hypoglycaemia
hypoalbuminaemia
non-specific (condition/weight loss…)
what clinical sign can hypoalbuminaemia lead to in liver disease cases?
ascites
what effects does hepatic disease have that can cause circulatory disturbance (ascites)?
hypoalbuminaemia
portal hypertension
sodium/water retention
what can cause an acquired portosystemic shunt?
cirrhosis
portal hypertension
what is the main consequence of a portosystemic shunt?
hepatic encephalopathy - toxins that would normally be eliminated aren’t (build up of NH3 in blood)
what are the clinical signs of hepatic encephalopathy?
anorexia, vomiting, diarrhoea
blindness, aggression, staggering, seizures
what can make hepatic encephalopathy worse?
high protein meal
GI bleed
dehydration
acid-base imbalance
what are clinical signs of hepatic encephalopathy in cats but not dogs?
copper-coloured irises
salivation
why can excessive bleeding occur with liver disease?
liver produces/stores clotting factors
liver is responsible for vitamin K absorption
portal hypertension can cause GI bleeding
why is the liver partly responsible for vitamin K absorption?
it is a fat soluble vitamin and the liver produces bile acids that help to absorb fat
what are the clinical signs of liver disease?
icterus
faecal changes (grey, melaena)
hepatic encephalopathy
drug intolerance
ascites
stunted growth (due to metabolic effect)
vomiting/diarrhoea
PUPD
non-specific signs - anorexia, weakness…
what are the two divisions of hepatopathies?
primary (problem arisen in liver)
secondary/reactive (liver reacting to issue elsewhere)
what are the two types of primary hepatopathy?
inflammatory
non-inflammatory
what are the two types of primary hepatopathy?
inflammatory
non-inflammatory
what are some possible aetiologies of secondary hepatic disease?
anoxia
toxaemia
nutritional imbalance
metabolic changes
infection
what are some bacterial causes of inflammatory hepatic disease?
leptospirosis
bacterial cholangiohepatitis
what are some viral causes of inflammatory hepatic disease?
infectious canine hepatitis
canine herpes
feline infectious peritonitis
what protozoa can cause inflammatory hepatic disease?
toxoplasma
what are some non-infectious inflammatory causes of hepatic disease?
toxic hepatic disease
drug-induced hepatic disease
canine chronic hepatitis
feline lymphocytic cholangitis
what are some causes of non-inflammatory hepatic disease?
congenital portosystemic shunt
juvenile heaptic fibrosis
feline hepatic lipidosis
neoplasia
telangiectasis
surgical - torsion/trauma
what are some causes of non-inflammatory hepatic disease?
congenital portosystemic shunt
juvenile heaptic fibrosis
feline hepatic lipidosis
neoplasia
telangiectasis
surgical - torsion/trauma
what is the reason for cats susceptibility to paracetamol and aspirin?
deficiency of gluruonyl transferase meaning they have difficulty conjugating toxins
what is paracetamol toxic to cats?
deficiency of glucuronidation
deficiency of glutathione conjugation
how is paracetamol toxicity treated?
N-acetylcysteine (precursor for glutathione)
vitamin C
supportive treatment
why is coagulation often tested in cases of suspected hepatic disease?
check if a liver biopsy can safely be taken
what do liver enzymes test for?
suggest liver disease (nothing to do with function!!!)
what is the most common hepatocellular marker used in serum biochemistry?
ALT
what is the most common cholestatic marker used in serum biochemistry?
ALP
what can be tested to give an indication of liver function?
serum proteins (albumin)
glucose, urea, cholesterol
bilirubin
bile acids
ammonia
what are the four reasons for low albumin?
protein losing enteropathy
protein losing nephropathy
decreased production
blood loss
how can radiographs be used to determine overall liver size?
mass effect on other organs (stomach)
what are the indications for a liver biopsy?
persistent increases in liver enzymes
altered liver size
monitoring progressive liver disease
evaluated response to treatment
what must always be done before taking a liver biopsy?
clotting profile (APTT or PT)
what are some contradictions for percutaneous liver biopsy?
lack of operator experience
small liver
focal disease
extrahepatic cholestasis
bleeding disorder
severe anaemia
when does juvenile hepatic fibrosis occur?
first two years of life
what breeds are predisposed to juvenile hepatic fibrosis?
German shepherd
Rottweiler
what is the main pathology seen in juvenile hepatic fibrosis?
progressive fibrosis
minimal inflammatory reaction
central vein fibrosis/occlusion
what caused acquired portosystemic shunts to develop?
secondary liver disease - juvenile fibrosis, cirrhosis…
what are the four different patterns of canine chronic hepatitis?
idiopathic chronic hepatitis
lobular dissecting hepatitis
drug-induced chronic hepatitis
copper-associated hepatitis
what are some features that are a poor prognostic indicator in chronic hepatitis?
hypoalbuminaemia
bridging fibrosis/severe necrosis and fibrosis
what is hepatic portal hypoplasia?
microscopic intra-hepatic shunting often with no clinical signs (can have similar signs to portosystemic shunts)
what are the two patterns of feline cholangitis complex?
suppurative cholangitis
lymphocytic cholangitis
