Oesophageal Disease and Vomiting in SA Flashcards
Name 4 Oesophageal disease categories and highlight the 3 common causes
1) Anatomic
Vascular ring anomaly, cricopharyngeal disease, hiatal hernia, divericulum
2) Obstruction
Mural (structure, wall) , Luminal (FB), Extraluminal (mass)
3) Oesophagitis
trauma, reflux (anaethesia), irritation
4) Motility Disorders
Megaoesophagus, neuropathy, myopathy
3 common causes:
Oesophagitis
Oesophageal foreign body
Mega-oesophagus (Chest X-ray - air-filled/dilated)
Define Regurgitation and name some clinical signs
Definition: disease of the oesophagus - problem with transport and/or reflux
CS: hypersalivation, odynophagia (pain on eating), anorexia, Dysphagia (difficulty swallowing), nasal discharge, coughing
Name the difference between Regurgitation Vs Vomiting
R is a passive event compared to the abdominal effort seen in V
R usually involved soon after eating and V is random
Possibly painful in R (obstruction/inflammation)
V usually consists of digested food (gone through to duodenum (so Alkaline/Acidic pH) compared to R (usually alkaline pH)
V presents with prodromal nausea (before event-indicates onset)
Name some PE diagnostics and Investigations for V and R
PE:
Oesophageal palpation - starts superficial and goes deep in the neck
Lung auscultation - Aspiration pneumonia (cracking/gurgling)
Body condition
Underlying/ concurrent disease
Usually normal in oesophageal disease
Investigations:
Haematology & Biochemistry
Diagnostic imaging - plain/contrast radiography - outline lesions/tumors
Endoscopy
Megaoesphagus:
1) Name a few differential diagonoses
2) What you would see on a Radiograph
3) Treatment
1) Common causes: Idiopathic M (dogs) Myasthenia gravis (generalised/focal) - certain muscles in body to weaken Thymona (tumour of the Thymus) Hypoadrenocorticism (Addison's disease)
2) Radiograph - in the chest - the oesophagus will appear as a black mass (lucent) - air filled and dilated
3) Treat underlying disease Elevated food/water bowl hold vertical after feeding Experiment with food consistency - liquid - can easily aspirate, solids - more difficult to swallow (AP associated with MO)
Why does Aspiration Pneumonia occur?
Larynx does not close when regurgitation occurs - no reflex - airway is not protected
Common and life threatening
Can occur in R and V
Oesophagitis
1) Define
2) Causes
3) DDX
4) TX
1) Inflammation of the Oesophagus
2) Chemical injury - corrosive agents, medications (doxycycline) (in cats remember to flush)
Gastro-oesophageal reflux (poorly positioned feeding tube, persistent vomiting, GA, hiatal hernia - hiatus (hole in diaphragm - oesophagus attaches to stomach - stomach goes through hiatus)
Oesophagus FB - Lodged at thoracic inlet, heart base, hiatus - NEEDS retrieval (eg endoscopy, through stomach) - perforation, mucosal damage
3) Endoscopy - inflammation
4) Dietary - small meals, high protein-low fat food (minimises reflux), feeding tubes
Sucralfate liquid - chemical bandage - let mucosa heal - good for FB lesions
Inhibitors of gastric acid secretion (reduce reflux)- H2 blockers, proton pump inhibitors (omeprazole)
POOR PROGNOSIS - strictures (narrowing/tightening of O - swallowing difficulties)
Describe Vomiting: The process and causes
Process: Forceful expulsion of GI contents from the mouth - usually a mechanism to eliminate toxins. This isn’t a disease but a symptom of one.
Causes: Metabolic/endocrine disease, GI (1^o and 2^o)/abdominal, systemic, neurological & toxic diseases
Name 3 pathophysiological ways of Vomiting
The 3 ways end up at the Vomiting centre in the Brain stem causing V:
1) Due to external blood-borne substances - Drugs, toxins, Uraemia (Kidney disease), Infections, Motion sickness - triggers the chemoreceptor trigger zone in the Brain stem and then to VC
2) Cats/dogs/humans: Vomiting triggered by memory - cortex - to VC
3) In the stomach - stretch receptors- from gastritis and pain - Vagal and Sympathetic afferents to VC
How can you define/refine the problem of Vomiting
1) Chronicity - acute/chronic (over 2/3 weeks)
2) Lesion - 1^o GI or 2^o GI (associated - metabolic)
Name Primary GI, acute and chronic causes of Vomiting:
Primary GI:
ACUTE: Dietary (indiscretion - getting into rubbish, intolerance - more common than H - lack specific enzymes to break down particular food, hypersensitivity), Infectious diseases (parvoviruses - puppies and parasites), obstruction - FB, gastric hypertrophy and neoplasia, gastric volvulus/Motility disorders
CHRONIC: Neoplasia, Inflammatory disease - IBD/Ulceration/gastritis
MOST COMMON ARE:
Dietary, Obstruction, Infection, Inflammatory disease
Name Metabolic chronic causes of Vomiting and the Work up for Chronic patients:
Uraemia, Addison’s disease (hypoadrenocorticism), Hepatic disease, Pancreatitis - common in Dogs, toxin ingestion
All these 2^o metabolic diseases very common but usually will have other clinical signs - blood borne
Work up:
Biochemistry and Haematology work up - organ disease
Urinalysis - are kidneys concentrating
Radiographs - obstruction - (dilation of I cranial to O)
Ultrasound (other organs- are they abnormal?)
Endoscopy - last resort
Treatment of Vomiting
Acute: Stop feeding - symptomatic treatment
Chronic: treat underlying problem
Causes of Gastric Ulceration and how to diagnose?
Many causes of GU - but can distinguish between the aspect of lesion/ history/ clinical signs/blood work
a) Neoplasia - lymphoma, carcinoma (tumour starting from epithelial cell layer, leiomyoma (benign smooth muscle neoplasm) - look at aspect - single ulcer not spread out - not N
b) Iatrogenic: NSAIDS - common in D and C (U in duodenum as well)
Diagnosis: Endoscopy - an area of thickened stomach wall - deep lesion compared to superficial lesion in neoplasia
c) Inflammation - gastritis
d) Systemic - determined by bloodwork - hypoadrenocorticism, Uraemia, liver dysfunction, mast cell tumour, gastrinoma
e) Hypotension - seen in clinical signs and history - shock, sepsis (septicaemia), disseminated intravascular coagulation
f) other/idiopathic - stress, spinal surgery
Pros and Cons for using rational Anti-Emetic Therapy and name some drugs available:
Treat the vomiting ONLY if debilitating - pain or heavy electrolyte/fluid loss
Could mask issue underlying which is the most appropriate treatment
Sometimes contradictory - used to expel toxins - protective mechanism
Drugs:
Metoclopramide - (Tablets/injection/suspension)
Para-aminobenzoic acid derivative with central + GI effects
Antagonises the D2- dopaminergic + HT3 receptors in CRTZ + peripheral cholinergic effect
Also a prokinetic agent for upper GI tract - helping increase motility - if suspect delay
FIRST LINE TREATMENT! - good - not that potent
Ondansetron - POTENT for best anti-emetic for V (blood borne) and chemotherapy induced nausea
5-HT3-Serotonergic antagonist
Expensive
Good for pancreatitis if nothing else works
Maropitant - newly licensed - V POTENT - can mask
neurokinin-1 receptor Antagonist - Neurotransmitter between CRTZ to vomiting centre - any input from peripheral or cortex or motion sickness or metabolic diseases - will converge to this receptor and so stops all vomiting if antagonised
Don’t miss another diseases such as acute obstruction - MAKE sure will stop V but not problem
