Oesophageal diseases and Vomiting

Question 1

Clinical signs of regurgitation

Answer 1

hypersalivation 
odynophagia (pain on eating) 
anorexia 
Dysphagia (difficulty swallowing) 
nasal discharge 
coughing

Question 2

Regurgitation vs. Vomiting - Vomiting

Answer 2

Abdominal effort
Prodromal nausea
Usually digested food
No swallowing pain

Question 3

Regurgitation vs. Vomiting - regurgitation

Answer 3

Passive event
No prodromal nausea
Undigested food
Possibly painful

Question 4

diagnosis

Answer 4

signalment
history
PE - usually normal for oesophageal disease

Question 5

diagnosis - investigations

Answer 5

Haematology & biochemistry
Other blood tests, urine analysis etc.
Diagnostic imaging - Plain radiography, Contrast radiography
Endoscopy

Question 6

DDx for regurgitation - 3 most common

Answer 6

Oesophagitis
Oesophageal foreign body
Mega-Oesophagus

Question 7

DDx for regurgitation - anatomic

Answer 7

Vascular ring anomaly, cricopharyngeal disease, hiatal hernia, diverticulum

Question 8

DDx for regurgitation - obstruction

Answer 8

Mural (stricture)
Luminal (FB)
Extraluminal (mass)

Question 9

DDx for regurgitation - oesophagitis - causes

Answer 9

trauma, reflex, irritation

Question 10

DDx for regurgitation - motility disorders

Answer 10

Megaoesophagus, neuropathy, myopathy

Question 11

mega-oesophagus - common causes

Answer 11

Idiopathic megaoesophagus (dogs)
Myasthenia gravis (generalised or focal)
Thymoma
Hypoadrenocorticism

Question 12

aspiration pneumonia

Answer 12

Regurgitation is not associated with reflex closure of the
larynx
Airway is unprotected
Aspiration pneumonia is common
Potentially life-threatening
oesophageal dysfunction & laryngeal paralysis is a bad combination

Question 13

oesophagitis - causes

Answer 13

Chemical injury - corrosive agents, medications
gastro-oesophageal reflux - General Anaesthesia, hiatal hernia, persistent vomiting, poorly positioned feeding tubes
Oesophageal foreign bodies (FBs)

Question 14

oesophagitis - treatment

Answer 14

Dietary – small meals, high protein-low fat food to minimise reflux +/- gastric feeding tube
Sucralfate liquid – chemical bandage
Inhibitors of gastric acid secretion

Question 15

oesophagitis - possible serious complication

Answer 15

strictures

Question 16

oesophageal FB

Answer 16

Lodge at thoracic inlet, heart base, hiatus
Bones, fish hooks, toys, needles, sticks
Endoscopic retrieval or push to stomach
Potential for mucosal damage/perforation
Should be considered an emergency
Needs endoscopy

Question 17

primary causes of vomiting

Answer 17

Dietary (acute) - indiscretion, intolerance, hypersensitivity
Infection (acute) - parasites, parvovirus
Inflammatory disease (chronic) - gastritis, IBD, ulceration
Neoplasia (chronic)
Obstruction (acute) - neoplasia, foreign body, gastric hypertrophy
Motility disorders/gastric volvulus (acute)

Question 18

secondary causes of vomiting

Answer 18

Uraemia 
Addison’s disease (adrenocortical insufficiency) 
Hepatic disease 
Pancreatitis 
Toxin ingestion (acute) 
Drugs

Question 19

regulation of acid secretion - drug types

Answer 19

prevents gastric ulcers
anti-histamines
anti-cholinergics
proton-pump inhibitors

Question 20

sucralfate

Answer 20

Oesophageal and gastric ulceration
Aluminium hydroxide and sucrose octasulfate
Dissociates in acid
Sucrose octasulfate reacts with HCl and is polymerised to viscous sticky substance that binds to proteinacious exudate usually found at ulcer sites
Protective barrier
Stimulates HCO3 - mucus & prostaglandin secretion

Question 21

Cimetidine/Ranitidine/Famotidine

Answer 21

HA (H2) receptor antagonist
inhibition of gastric acid
some gastric prokinetic activity
Used frequently to treat any sort of regurgitation/vomiting
No evidence that there is any efficacy in dogs or cats

Question 22

omeprazolne

Answer 22

Proton pump inhibitor
Binds parietal cells, irreversibly blocking H+/K+ ATPase - inhibits the transport of H+ into the stomach
gastric hyperacidity
GI ulcers and erosions
Zollinger-Ellison syndrome (gastrinoma)
Long duration of activity – once daily dosing

Question 23

Anti-Emetic Therapy

Answer 23

Used if vomiting is debilitating - pain, marked fluid and/or electrolyte loss
management of the underlying disease
Cause cannot be determined in all patients
Anti-emetic therapy may not always be desirable
Vomiting can be protective

Question 24

metoclopramide

Answer 24

Para-aminobenzoic acid (PABA) derivative with central and GI effects
Antagonises D2-dopaminergic & 5-HT3 receptors in the CRTZ & peripheral cholinergic effect
Upper GI prokinetic agent

Question 25

ondansetron

Answer 25

5-HT3-Serotonergic antagonist
expensive
Best anti-emetic for chemotherapy-induced nausea and vomiting
Also good for pancreatitis

Question 26

maropitant

Answer 26

Neurokinin-1 receptor antagonist
Central and peripheral effects
Stops the binding of substance P
Very potent: Careful, masks underlying diseases!
licensed for use in dogs- soon also cats
useful in any kind of vomiting