SA GI disease Flashcards

Question

Vomit reflex?

Answer 1

``` Contract pylorus Relax stomach and LOS Contract abdominal muscles Thorax vs closed glottis Open UOS Antiperistalsis ```

Answer 2

``` Infections - distemper, lepto Pyometra Renal failure Hepatic disease Drugs - digoxin, erythromycin, morphine Ketoacidic DM Hypoadrenocorticism CNS disease - motion sickness, vestibular disease Neoplasia ```

Answer 3

Inflammatory bowel disease Intestinal neoplasia Small intestinal obstruction Pancreatitis

Answer 4

``` Chronic gastritis Gastric retention disorders Gastric ulcers Gastric neoplasia Diffuse GI disease involving stomach - inflammatory bowel disease, alimentary lymphoma ```

Answer 5

Vomiting Haematemesis Nausea - hypersalivation, retching, anorexia Melaena Miscellaneous - belching, bloating, borborygmi, weight loss

Answer 6

Gastric outflow obstruction Gastroparesis Disruption of mucosal barrier

Answer 7

Distinguish vomiting vs regurgitation Eliminate secondary causes - Hx, PE, lab analysis, imaging Abdominal imaging - plain radiography, contrast radiography, ultrasonography Gastroscopy/coeliotomy Symptomatic treatment

Answer 8

Oral exam - ulcers, linear foreign body Abdominal palpation - pain, foreign body, intra-abdominal mass, distended stomach or bowel Rectal exam - diarrhoea, melaena

Answer 9

Haematology Biochemistry Urinalysis - no pathognomic changes, more used to rule out systemic disease, also can assess hydration status

Answer 10

``` Radiography: survey abdominal radiograph - foreign body - abdominal mass - intestinal obstuction - peritonitis - GDV Ultrasonography: - foreign bodies - ulcers - thickening of gastric mucosa - loss of layering (suggests infiltration) ```

Answer 11

If clinical or radiographic signs of gastric disease Inspection and biopsy (even if grossly normal) Foreign body removal

Answer 12

``` Aetiology usually unknown Sometimes generalised IBD Chronic gastric parasitism Hairballs in cats? Spiral bacteria - Helicobacter? Immune mediated? ```

Answer 13

Intermittent chronic vomiting (vague) +/- periodic early morning vomit with bile +/- poor appetite +/- gastric bleeding

Answer 14

Lab changes often non specific Imagining findings non specific Gastroscopy and biopsy

Answer 15

Removal of etiologic agent if known Diet - multiple small meals, low fat diet (fatty foods stay in stomach longer), hypoallergenic diet (novel protein source, hydrolysed protein) Acid blocker Corticosteroids?

Answer 16

Retention of food for >8h causing delayed vomiting of food Anatomical flow obstruction Functional disorder - primary motility disorder - inflammatory disease (IBD, gastric ulcer)

Answer 17

Pyloric stenosis Neoplasia, polyp CHPG Foreign body

Answer 18

Often occurs in dogs fed once daily (especially if fed in the morning) Vomiting occurs overnight or in the morning Vomitus often bile stained fluid, not food Presumably reflects abnormal ... Diagnosis - rule out other causes of vomiting, treatment trial Treatment - feed more often focussing on late meal, pro kinetics (ranitidine or metaclopramide)

Answer 19

Congenital in brachycephalic breeds Association with megaoesophagus in cats Treatment: pylorotomy/pyloroplasty

Answer 20

Idiopathic mucosal hypertrophy May cause outflow obstruction Most common in toy breeds Treatment - surgery

Answer 21

Treat underlying inflammatory disease Prokinetics - metaclopramide: stimulates normal gastric peristalsis - ranitidine: H2 antagonist plus pro kinetic action - erythromycin: low dose stimulates motilin receptors

Answer 22

``` Generalised bleeding Swallowed blood - oropharyngeal, nasal, pulmonary Severe gastritis Gastric ulcer Gastric neoplasia Duodenal disease ```

Answer 23

``` Haematemesis Melaena Anaemia Weight loss Pain Peritonitis etc if perforated ```

Answer 24

``` Drugs - NSAIDs, corticosteroids Head and spinal injuries - in combination with corticosteroids, also colonic ulcers/perforations Gastritis Metabolic - liver disease, uraemia Bile reflux? Mastocytosis Gastrinoma (Zollinger-Ellison) Spiral bacteria - Helicobacter? ```

Answer 25

``` H felis H heilmannii H bizzozeroni others High prevalence (~100%) - seen on biopsy Evidence of recognition by host - Ab response, lymphoid follicles Often no evidence of clinical disease But a cause of chronic gastritis? ```

Answer 26

``` Treat identifiable primary cause Sucralfate Acid blockers - antacids, H2 antagonists (cimetidine licensed but poss poor efficacy and side effects, ranitidine can be used for motility disorders under cascade), proton pump inhibitors (omeprazole) Antibiotics? Triple therapy? ```

Answer 27

Limited protective effect: H2 antagonists, PPis, sucralfate | Protective: synthetic PGE (misoprostol)

Answer 28

2 antibiotics plus an acid blocker e.g. amoxicillin, metronidazole and omeprazole Or 3 antibiotics e.g. amoxicillin, metronidazole and clarithromycin (works on luminal and intracellular)

Answer 29

``` Infiltrate gastric wall - fibrosis/thickening, ulceration Often lesser curvature/distal stomach Metastasis to local LN and liver Predisposition in Belgian shepherds, collies, bull terriers Suspect in older animal with: - chronic vomiting - anorexia and weight loss - haematemesis and melaena - anaemia - drooling saliva ```

Answer 30

``` Primary neoplasia infrequent Middle age/older male dogs > cats Dogs: - adenocarcinoma (75%) - lymphoma - polyps - leiomyoma/leiomyosarcoma Cats: - lymphoma - adenocarcinoma ```

Answer 31

Contrast radiography Endoscopic biopsy - often to superficial Full thickness biopsy

Answer 32

Surgical resection (palliative, rarely curative) Grave/hopeless prognosis - probably painful 'Leather-bottle' stomach

Answer 33

``` Advs: - quick - allows global overview - assessment of thorax and spine - allows differentiation of gas/mineralisation Disadvs: - superimposition - lack of contrast - soft tissue/fluid same opacity ```

Answer 34

Take on expiration Low kVp, high MAS Grid if >10cm Projections: VD, right lateral, +/- left lateral

Answer 35

``` Advs: - improves sensitivity - identification of anatomy not seen on plain radiographs (e.g. urethra or ureters, blood vessels) - allows assessment of internal structure - some info on function Disadvs: - time consuming - expensive - complications ```

Answer 36

Appropriate patient restraint (Ga often required) Requires food patient preparation - enemas (LUT, LI studies) Take plain images first Obtain enough images - genuine lesions are consistent and reproducible

Answer 37

``` Air, N20, CO2 Used for bladder and gastric studies Cheap, simple and minimal risk Air embolus reported, poor mucosal detail Reduce exposure ```

Answer 38

``` Radiopaque (higher atomic number) Water soluble (iodine based) Non soluble (barium) Iodine based agents divided into: - ionic and non-ionic - high osmolar and low osmolar Increase exposure ```

Answer 39

``` Advs: - assessment of internal architecture - assessment of vasculature - better soft tissue contrast - guided biopsy - accurate measurement - real time assessment motility Disadvs: - limited field of view - difficult if large amounts of gas - operator and equipment dependent ```

Answer 40

``` Surgical planning Tumour staging Retroperitoneal disease Parenchymal organs (larger dogs) Vascular malformations Ureters Insulinoma (esp large dogs) Pelvic canal ```

Answer 41

GIT Small dogs/cats Severe renal disease - need IV contrast

Answer 42

Identify if lesion accessible Allows visualisation of needle 21-22G Assess coagulation times and platelets if perform Tru-cut biopsy Avoid FNA bladder tumours Avoid crossing body cavities Catheter biopsy for bladder/urethral masses

Answer 43

Check extra-abdominal structures Assess boundaries of abdomen Assess serosal detail - relies upon fat between organs Assess each organ system 5 opacities Roentgen signs - size, shape, margination, opacity etc

Answer 44

Reduced fat - check body condition | Effacement by fluid/ST (ascites, peritonitis)

Answer 45

``` Fluid anechoic Need to sample to determine type Look adjacent to liver and bladder Assess hepatic veins Dilation HV - right sided heart disease ```

Answer 46

Large volumes relatively easy to detect - caudal to diaphragm, around stomach/serosal surfaces Smaller volumes present as gas bubbles outside of GIT Always significant (unless recent ex-lap) Indicates rupture of hollow virus (gas producing peritonitis/penetrating trauma) Usually fluid present also

Answer 47

Space of fat opacity Primarily kidneys but also Lns, great vessels, adrenals Swelling and masses - increased soft tissue ventral to spine replacing/obscuring fat, ventral displacement of colon, assess ventral spine carefully LNs - ventral to L6/7 (not normally visible), may displace and compress colon/rectum - drain pelvic canal and pelvic canal and pelvic limbs (look for anal sac, bladder, prostatic disease, pelvic limb masses)

Answer 48

Not normally visible (may mineralise in cats) Large masses may displace kidneys ventrolaterally neoplastic disease may mineralise in dogs

Answer 49

``` Left renal artery and CVC landwarks Left adrenal is monkey nut shaped Right adrenal is arrow shaped May invade vessels incidental nodules common Still need endocrine testing ```

Answer 50

Focal enlargement - neoplasia, granuloma, abscess, cyst | Diffuse enlargement - inflammation, metabolic disease, infiltrative neoplasia, congestion

Answer 51

Usually chronic disease Mineralisation common Often irregular Poor correlation with function

Answer 52

More sensitive than size changes Often non specific - neoplasia, cysts, haematomas, granuloma No information on function

Answer 53

``` Often incidental Dystrophic - secondary to damaged tissue Metastatic - secondary to abnormal Ca/P Calculi Ingesta Neoplasia ```

Answer 54

Position relative to costal arch Shape of caudal margins (should be sharp) Caudoventral border sharp triangle Gastric axis perpendicular to spine - parallel to ribs

Answer 55

Mass effect of cranial abdomen Caudal displacement of stomach especially Focal enlargements - masses, cysts, abscess/granuloma

Answer 56

Cranial displacement/rotation of gastric axis Portosystemic shunts Cirrhosis Herniation

Answer 57

Portal veins echogenic walls Hepatic veins thin walled Lung/diaphragm interface hyperechoic Difficult to evaluate diffuse disease on US - may see change in echogenicity compared to spleen Easier to appreciate multifocal hepatic disease - metastatic tumour, lymphoma, nodular hyperplasia, granuloma, necrosis (FNA/biospy required)

Answer 58

Gall bladder size too variable to be helpful Dilation of common bile duct (normally <3mm in dogs, 4mm in cats) May see obstructing material along duct or at papilla Dilation of intrahepatic bile ducts if chronic (7d)

Answer 59

Strap like Head of spleen attached to stomach, caudal to gastric fungus and craniolateral to left kidney (DV view) Tail mobile Size variable

Answer 60

Requires subjective evaluation - rounded margins, shape changes (margins) Causes: GA/sedation in dogs (ACP/Thio), infiltration, inflammatory disease

Answer 61

Lesions involving tail east to see, especially if no peritoneal fluid Mid-ventral abdomen (caudal to stomach) (Caudo)dorsal displacement of small intestine Lesions involving head better seen on VD projection Size no indication of malignancy

Answer 62

Very common on US Often benign nodular hyperplasia/extramedullary haematopoiesis Hyperechoic modules - myleolipoma FNA

Answer 63

Interpretation can be difficult Must be carried our properly e.g. good patient preparation Time consuming, cost intensive, low diagnostic yield Complication if GI perforation So superseded by combining radiography with US

Answer 64

Cervical part - dorsal to left lateral to the tracheal | Thoracic part - within mediastinum, returns to dorsal to the trachea and passes right to the aortic arch

Answer 65

Variation of normal oesophagus Brachycephalic breeds Contributes to increased opacity and width of the cranial mediastinal region Often not clinically significant

Answer 66

Segmental or generalised dilation May cause ventral deviation of the trachea and widening of the mediastinum Tracheo-oesophageal stripe sign (summation of tracheal wall and oesophageal wall) is normal

Answer 67

Thoracic inlet, heart base and cranial to the diaphragm/cardia Often mixed opacity, dorsally and ventrally well defined mass lesion in the region of the oesophagus (need orthogonal views) Endoscopy or non-ionic contrast

Answer 68

Positional radiography useful (right and left view and VD +/- DV) as gas will move to the non dependent side within hollow viscus SO po

Answer 69

``` Cardia Fundus Body Pyloric antrum Pylorus ```

Answer 70

Positioned within the costal arch in the cranial abdomen, directly caudal to the liver

Answer 71

Serosa, muscularis, submucosa, mucosa, luminal surface Muscularis and mucosa are hyperechoic Rugal folds are visible in fungus and body (esp in cats) Gas in fungus often impairs assessment Pylorus is a thick muscular structure relatively hyperechoic with seemingly blurred layering

Answer 72

Radiography: - easy to identify if mineral or metallic opacity - gas may be trapped in textile or botanical FB or toys -> bizarre gas patterns - may cause partial or complete obstruction e.g gastric distension with fluid in anorexic animals, 'gravel sign' US: - not always easy to discern from food - often hyperechoic surface and strong distal shadowing - more difficult if texture or absorptive material and very difficult if linear FB

Answer 73

Gas dilation - aerophagia, GD, DDG - dark opacity Fluid and gas dilation - pyloric outflow obstruction (functional ileum, obstruction) - mainly soft tissue opacity with gas opacity floating on top

Answer 74

Marked gas dilation and rotation around longitudinal axis Most commonly clockwise rotation: - pylorus shifts dorsally, cranially and to the left - body shifts towards the right - fundus displaced ventrally and to the right - spleen follows greater curvature towards the right (gastrosplenic ligament)

Answer 75

All parts of stomach markedly gas distended Fundus displaced caudoventrally and right Pyloric antrum displaced craniodorsal and left Compartamentalisation with a dividing soft tissue band ('shelf') Mass effect on other abdominal organs

Answer 76

e.g. neoplasia, haemorrhage, oedema Often not visible on plain radiographs US useful Localised or diffuse wall thickening (has to be substantial before can be reliably detected) Irregularly marginated gas content Delayed gas emptying due to partial/complete obstruction Imaging insensitive for ulceration

Answer 77

Normally smoothly marginated band/tube or as circular/ovoid ST opacity when viewed end on Usually of ST opacity with some segments being mildly homogenously gas filled in dogs Little to no gas filling in cats

Answer 78

Dilation with gas or fluid of SI associated with obstruction, but increased overall size may be due to diffuse wall thickening (hard to assess) No one loop more than 2x diameter of any other loops Dog: 2x width of a rib or 1.6x height of L5 at its narrowest point Cat: 12mm or 2x height of mid L4 or <2x height of endplate of L2 Wall thickness cannot be reliably assessed on plain radiographs - 'wall' is summation of true wall and intestinal luminal fluid - fluid and ST indistinguishable, requires contrast or ultrasonography

Answer 79

Mucosa is thickest layer Duodenum thickest wall of SI segment (5mm in dogs, 3-4mm in cats) Submucosa is thicker in the ileum and flower-like/wheel-like appearance on transverse images

Answer 80

``` Functional ileus secondary to: - severe inflammation (e.g. parvo) - peritonitis - recent surgery - drugs - thrombosis - mesenteric volvulus Mechanical or obstructive ileum secondary to: - obstruction (FB, intussusception) ```

Answer 81

Failure of intestinal contents to pass normally

Answer 82

Fluid and/or gas dilation proximal to the obstruction Creates two populations of intestine - one abnormal proximal and one normal distal to obstruction (may not see 2 populations if obstruction very proximal or very distal)

Answer 83

When partial obstruction Accumulation of many small mineralised particles proximal to the partial obstruction Typically little dilation Can also be seen in the stomach with pyloric/proximal duodenal obstruction

Answer 84

Secondary changes depending on level of obstruction: - fluid dilation proximal to FB and to-and-fro movement - normal intestines caudal to obstruction Foreign body - hyperechoic, irregular or artificially symmetrical shape - usually strong distal shadowing - focally dilating the SI/thin wall

Answer 85

Usually cause plication/hair-pin bends/bunching and triangular/tear-drop shaped gas bubbles +/- Localised peritonitis (loss of serosal detail, streaky appearance) Signs of obstruction (often less severe)

Answer 86

Ovoid/elongated ST mass/dilation Possibly crescent shaped gas opacity between intussusceptum (inner) and intussuscipiens (outer) No 'normal' caecal gas, shortened colon

Answer 87

Easily diagnosed on US Onion ring/bullseye appearance on transverse images Intestinal walls identified within intestinal lumen Also vessels/blood flow within lumen

Answer 88

Often normal Radiography not useful Ultrasound may show: - altered mucosal echogenicity - muscularis thickening (cats ddx: lymphoma) - normal to mildly thickened overall wall thickness - preserved layering

Answer 89

Needs to be substantial size for plain radiography Signs secondary to obstruction may be seen Care not to over interpret 'wall thickening' Large masses may not be possible to determine origin Localised masses, irregular gas filling/ccontrast column US very useful - loss of wall layering, often circumferential, hypo echoic or heterogeneous - may be very large with central gas containing lumen - may see signs of obstruction - assess local LNs

Answer 90

Located in right dorsal aspect of abdominal cavity, often level of left kidney Small in cats, rarely contains gas and normally not visible or comma shaped In dogs appears as semicircular snail-shell gas filled structure

Answer 91

Divided into ascending, transverse and descending colon Thin walled, distensible tube 'Question mark' shaped in DV projection

Answer 92

Large intestinal dilation with increasingly more opaque (dehydrated) faecal material Dog: < length of L7 vertebral body Cat: megacolon > 1.48x length L5 or 2.8x cranial endplate of L2 Idiopathic, neurogenic (spinal disease, dysautonomia), chronic constipation, chronic inflammation

Answer 93

Not seen in normal plain radiographs Medial to duodenum, between gastric body and transverse colon, medial to spleen and cranial to left kidney US more useful

Answer 94

Pancreatitis or neoplasia Lateral displacement of the duodenum and caudal displacement of the colon Increased ST opacity in the craniodorsal to mid abdomen Localised loss of serosal detail Functional ileus may lead to gas filling of the duodenum with pancreatitis

Answer 95

``` Enlarged hypoechoic pancreas Irregular margination Heterogeneous appearance Steatitis/hyperechoic mesentery +/- biliary obstruction Corrugation of duodenum ```

Answer 96

``` Adverse reactions to food IBD Antibiotic responsive diarrhoea (dogs) Lymphangiectasia Lymphoma/tumours Infectious diarrhoea Obstructions Liver disease Renal disease Pancreatic disease Endocrine disease - Addison's, DM, hyperthyroidism ```

Answer 97

``` Increased volume Colour change Normal to slight increase in frequency +/- weight loss +/- flatulence, borborygmi, halitosis ```

Answer 98

``` Decreased volume Increased frequency Urgency and tenesmus Mucus and haematochezia Dyschezia Constipation +/- variable consistency No weight loss? ```

Answer 99

= digested blood so a sign of upper GI disease (stomach or SI bleeding)

Answer 100

Starve for 48h Polyethylene glycol (laxative) - 3 doses 4h apart with stomach tube Followed by 2 x warm water enemas

Answer 101

1. Faecal analysis - parasites (Giardia, Cryptosporidia, Tritrichomonas foetus-cats) - bacteria? (Salmonella, Campylobacter) - although may not be cause 2. Haematology, serum biochemistry and urinalysis - to rule out systemic diseases (liver/kidney disease etc) 3. Endocrine tests - ACTH stim test/basal cortisol (hypoadrenocorticism) - total thyroxine (hyperthyroidism) - trypsin-like immunoreactivity (TLI) (exocrine pancreatic insufficiency) - total lipase or pancreatic lipase (possible pancreatitis) - folate and cobalamin (malabsorption)

Answer 102

``` Multi cat environment Poor body condition Chronic diarrhoea Large intestinal signs Diagnosis - faecal prep in saline, culture, PCR (best) ```

Answer 103

Negative prognostic indicator | Needs treating with cobalamin - SC injection (needed in some dogs with problem absorbing cobalamin) or oral

Answer 104

Endoscopy: - minimally invasive and direct examination - requires equipment and expertise - small superficial samples from a limited region Coeliotomy: - can get multiple full thickness biopsies - surgical risk - best for cats (more likely to miss disease with endoscopy)

Answer 105

``` Non specific normal/mild inflammation: - adverse reaction to food- antibiotic-responsiveness diarrhoea etc - IBD (chronic enteropathy) Moderate-severe inflammation: - IBD (chronic enteropathy) Lymphoma Lacteal dilation: - lymphangiectasia - secondary to another disease ```

Answer 106

Diet - food responsive? Antibacterials - antibiotic responsive? Steroids - IBD? Cytotoxics - severe IBD or lymphoma?

Answer 107

Difficult, incomplete or infrequent evacuation of dry hardened faeces from the bowel

Answer 108

Dietary - ingested foreign material, low residue diet Neuromuscular - spinal cord disease (lumbosacral), idiopathic megacolon Environmental - obesity, hospitalisation, change in routine, inactivity Colonic obstruction - stricture, pelvic trauma, neoplasia, foreign body Electrolyte imbalance - dehydration, hypokalaemia Drug-induced - opiates, phenothiazines, anticholinergics

Answer 109

Radiography

Answer 110

Remove underlying cause if possible e.g. surgery for fracture Oral laxatives - lactulose, polyethylene glycol (Cisapride) - not licensed Enemas Gentle manual evacuation under anaesthetic Surgery if megacolon Dietart management - high fibre

Answer 111

Inflammatory disease of intestines, pancreas and liver

Answer 112

Normally trypsin only activated in SI Aetiological factors triggers early activation in pancreas Activated trypsin triggers activation of other proteases Results in autodigestion of pancreas - direct tissue damage Cascade initiation: - coagulation - fibrinolysis - complement - kallikrein-kinin

Answer 113

``` (mostly idiopathic) Breed - spaniels and terriers Gender - females, neutered Obesity Drugs Concurrent diseases Dietary factors - hypelipidaemia predisposes to obesity and diabetes mellitus, primary hyperlipidaemia in miniature schnauzers (not proven) - high dietary fat - dietary indiscretion ```

Answer 114

Cholangitis IBD Hepatic lipidosis Diabetes mellitus

Answer 115

``` Dehydration (97%) Anorexia (91%) Vomiting (90%) Weakness (79%) Abdominal pain (58%) - prayer position Diarrhoea (33%) Jaundice (32%) ```

Answer 116

``` Lethargy (100%) Anorexia (93%) Vomiting (35%) Abdominal pain (25%) Diarrhoea (15%) ```

Answer 117

History/physical exam Lab tests Diagnostic imaging Biopsy

Answer 118

``` Haematology and biochemistry - increased WBCs - increased glucose/decreased calcium - increased liver enzymes - jaundice (increased bilirubin) Pancreatic enzyme tests - total amylase and lipase - pancreatic lipase (more specific but still not perfect, SNAP test) Results less consistent in cats ```

Answer 119

Radiography - to rule out other disease | Ultrasound - hyperechoic/hypoechoic, enlargement and swelling, mesenteric changes (hyperechoic)

Answer 120

Nutritional support - feed as soon as V+ stops with feeding tube - move onto interim diet: first small amounts of water, then start food cautiously (low fat diet, small frequent meals) Pancreatic enzymes as long as doesn't affect appetite - reduces pancreatic secretion to poss reduce post-prandial pain (no evidence of efficacy) - long term diet from 3 weeks onwards, pancreatic/weight management diet if obese Fluid therapy Analgesia - avoid NSAIDs - buprenorphine - paracetamol (dogs only) - tramadol - gabapentin Anti-emetics if V+ - allows early enteral nutrition Antibacterials - most cases are sterile - but intestinal wall 'leaky' -> bacteraemia so consider prophylactic use Steroids? Surgery?

Answer 121

1. Pancreatic acinar atrophy - most common in dogs - possibly heritable in GSD and rough collies (66% are GSDs) - lymphocytic infiltration so immune mediated? But only see cases when already atrophy so immuno-suppressives not effective treatment 2. Pancreatic hypoplasia - rare congenital (<6mo) - associated juvenile DM 3. Chronic pancreatitis - most common in cats (still rare) Rare in cats

Answer 122

Faecal changes - large volumes, foul smelling, greasy (steatorrhoea), putty-like to overt diarrhoea Appetite changes - polyphagia, coprophagia, pica Vomiting Poor coat condition Poorly muscled/weight loss

Answer 123

Trypsin like immunoreactivity: - Blood test - Best test - Normal dog TLI >5ug/L - Dogs with EPI <2.5ug/L - Equvocal 2.5-5ug/L (repeat in 4 weeks) - Subclinical EPI? repeatedly 2.5-5ug/L

Answer 124

``` Pancreatic enzyme - uncoated dry powder - enteric coated granules - fresh-frozen pancreas - mix with each meal and feed Feed highly digestible diet - no need to fat restrict - not high fibre - exclusion diet not necessary - ensure adequate food intake (2xM for ideal weight) Cobalamin supplementation if deficient - pancreas does not produce intrinsic factor - poor prognostic indicator Antibacterials for bacterial overgrowths? Acid blockers? Treat other diseases in cats (often other diseases present)! Good prognosis if treated correctly ```

Answer 125

Very similar to dogs Weight loss (or poor growth) Diarrhoea Polyphagia, coprophagia, anorexia, flatulence Vomiting Signs of any concurrent disease - lethargy, hair loss, PUPD, weakness

Answer 126

``` Novel protein source Sole dietary intake Minimum 2 weeks Occasionally 10-12 weeks Then ideally re-challenge ```

Answer 127

IBD Lymphangiectasia Alimentary lymphoma

Answer 128

Poor prognosis - survival may only be few months without appropriate therapy Go straight to immunosuppression - prednisolone (2-4 weeks, reduce over 2-3 months) - cytotoxic (chlorambucil best first choice)

Answer 129

Pre-hepatic - haemolysis Hepatic - hepatocyte dysfunction, intrahepatic cholestasis Post-hepatic - extra-hepatic cholestasis

Answer 130

Non specific signs - loss of condition, weight loss Hypoglycaemia Hypoalbuminaemia - only in chronic disease, can contribute to ascites

Answer 131

Hypoalbuminaemia Portal hypertension Sodium and water retention

Answer 132

Usually multiple Develop secondary to liver disease - juvenile fibrosis, cirrhosis, portal hypertension Shunts develop from redundant vessels between portal vein and caudal vena cava Portal hypertension often leads to ascites

Answer 133

``` Hepatic encephalopathy Defective urea formation from NH3 Increased blood NH3 (and other toxins) Leads to altered CNS function CNS signs: - anorexia, v+d, PUPD - dullness, aggression, staggering, blindness, head pressing, seizures - worse if high protein meal, GI bleed, dehydration or acid-base imbalance - increased sensitivity to anaesthetics ```

Answer 134

Portosystemic shunt

Answer 135

Defective production and storage of clotting factors Vitamin K malabsorption Portal hypertension -> GI bleeding

Answer 136

``` Icterus Faecal changes - grey, melaena Hepatic encephalopathy Drug intolerance Ascites Stunted growth (if young) Vomiting and diarrhoea Polyuria & polydipsia Non-specific signs • Anorexia • Weight loss • Weakness • Poor coat and skin condition ```

Answer 137

Primary - Infectious inflammatory diseases - Non infectious inflammatory diseases - Non infectious non inflammatory diseases Secondary (reactive) - most common, reversible

Answer 138

``` Anoxia Toxaemia Nutritional imbalance Metabolic changes Infection ```

Answer 139

``` IBD Bacterial infections Periodontal disease Acute pancreatitis DM HAC Hyperthyroidism Shock Septicaemia etc ```

Answer 140

``` Bacterial - Leptospirosis - Bacterial cholangiohepatitis Viral - Infectious canine hepatitis - Canine herpes virus - FIP Protozoal - Toxoplasma ```

Answer 141

``` Toxic hepatic disease Drug induced hepatic disease All forms of chronic hepatitis - canine chronic hepatitis - feline lymphocytic cholangitis ```

Answer 142

``` Congenital portosytemic shunt Juvenile hepatic fibrosis Feline hepatic lipidosis Neoplasia Telangiectasis and Peliosis Surgical - trauma - liver lobe torsion - entrapment ```

Answer 143

Relative deficiency of glucoronyl transferase So difficulty conjugating toxins (glucoronidation) Aspirin, paracetamol, phenols, pine tars, morphine, benzenes, alcohols, barbiturates Results in methaemoglobinaemia - haemolytic aneamia (depression, dyspnoea) - facial oedema - hepatocellular damage (liver failure and icterus)

Answer 144

``` N-acetylcysteine S-adenosyl methionine? IV fluids Antibiotics Activated charcoal if recent ingestion ```

Answer 145

Anorexia and weight loss most common Icterus relatively common PUPD - less severe Hepatoencephalopathy -> hypersalivation Microhepatica and cirrhosis rarely seen Pyrexia common in suppurative cholangitis Chorioretinitis or uveitis (FIP, toxoplasmosis)

Answer 146

``` Cholangitis complex FIP (dry form) Lymphoma Toxoplasmosis Lipidosis Pancreatitis Haemolytic anaemia Toxic hepatopathy Panleucopenia Neoplasia Biliary obstruction/bile duct rupture ```

Answer 147

Hepatocellular markers: ALT, AST | Cholestatic markers: ALP, GGT

Answer 148

ALT and ALP - early hepatitis Bile acids - chronic hepatitis, most sensitive test of function Albumin and bilirubin - cirrhosis Clotting factors and glucose - end stage

Answer 149

Normal: gastric axis parallel to ribs Hepatomegaly: gastric axis tilted caudally Microhepatica: gastric axis tilted cranially

Answer 150

``` Liver size Heterogenous parenchymal disease Biliary obstruction Biliary calculi Masses Vasculature - portosystemic shunts, arteriovenous fistulas ```

Answer 151

Persistent increases in liver enzymes Altered liver size Monitoring progressive liver disease To evaluate response to treatment

Answer 152

'Blind' percutaneous Ultrasound guided percutaneous ('Tru-cut' technique) Laparoscopy Coeliotomy

Answer 153

``` Lack of operator experience Small liver, unless ultrasound available Focal disease Extrahepatic cholestasis Bleeding disorder Severe anaemia ```

Answer 154

``` Acquired Progressive fibrosis Minimal inflammatory reaction Central vein fibrosis and occlusion most common Young GSD, Rottweiler ```

Answer 155

Ascites with the acquired shunts following hepatic fibrosis, and mostly GSD, Rottweiler Ascites rare in congenital portosystemic shunts

Answer 156

Idiopathic chronic hepatitis Lobular dissecting hepatitis Drug-induced chronic hepatitis Copper-associated hepatitis

Answer 157

Hypoalbuminaemia Severity of necrosis and fibrosis in the biopsy Bridging fibrosis

Answer 158

Aka microvascular dysplasia Microscopic intra-hepatic shunting Often have no clinical signs or like PSS Small terrier breeds Increased bile acids

Answer 159

Suppurative or lymphocytic cholangitis (or mix) | Sclerosing cholangitis - end stage

Answer 160

Biliary stasis Liver failure Anorexia Death

Answer 161

Similar to inflammatory liver disease | Hepatomegaly - can be irregular shape

Answer 162

Hepatocytes - hepatocellular carcinoma, hepatoma Biliary - cholangiocarcinoma Connective tissue - fibroma/sarcoma, haemangioma/haemoangiosarcoma

Answer 163

Dietary modification Ursodeoxycholic acid (UDCA) Anti-oxidant drugs and glutathione donors Treatment of complications Antibiotics if neutrophils on biopsy or positive bacterial culture Immunosuppressives if lymphocytes (immune mediated process) on biopsy - prednisolone +/- azathioprine Anti-fibrotics if fibrosis on biopsy - prednisolone +/- diet/UDCA Decoppering drugs if copper accumulation on biopsy - penicillamine, tridentine, Zn

Answer 164

Aim to minimise ammonia production Protein restriction High biological value - dairy, vegetable

Answer 165

Aim to reduce inflammation and prevent copper accumulation Alter mineral balance - low copper and high zinc Fat soluble vitamins - A, D, E, K, C? Taurine and L-carnitine for cats Protein restriction rarely required - feed as much protein as will tolerate, add cottage cheese to a standard 'hepatic diet' Anti-oxidants

Answer 166

Hepatic encephalopathy - use empirically based on clinical picture - ampicillin or metronidazole Bacterial cholangiohepatitis - documented infection, need culture and sensitivity (bile and tissue)

Answer 167

``` Advs: - improved well being - appetite stimulation - anti-inflammatory - immunosuppression - anti-fibrotic Disadvs: - steroid hepatopathy - predisposes to infection - fluid retention - catabolic ```

Answer 168

``` Bedlington terrier WHWT Skye Terrier Dalmatian Labrador Doberman ```

Answer 169

``` Copper chelators: - D-penicillamine - 2,2,2-tetramine Copper absorption blocker: - oral zinc (high zinc in commercial diets or use zinc supplement 1h before feeding) ```

Answer 170

``` Advs: - don't need biopsy results - broad spectrum of activity - wide safety margin - combination therapy used Disadvs: - cost - worse compliance if give many drugs? ```

Answer 171

Ursodeoxycholic acid (UDCA) - = hydrophilic bile salt - alters bile composition (decreases hydrophobic bile acids) - stimulates bile flow (contraindicated if complete biliary obstruction) - modulates inflammatory/immune response - limited evidence available in animals S-Adenosyl methionine (SAMe) - 'glutathione donor' for hepatic metabolism and detoxification - no clear evidence as a treatment in animals - might be useful for paracetamol toxicity in dogs - might help to reduce effects of chemotherapy or steroids Milk thistle - active agents: silychristine, silydianin, silybin - free radical scavneger - inhibits inflammation - inhibits lipid peroxidase - inhibits collagen deposition - increases glutathione - advs: wide safety margin, no absolute contraindications, broad spectrum of activity - disadvs: cost, no evidence of efficacy Vitamin E

Answer 172

Hepatic encephalopathy and coma - identify and treat precipitating cause (dehydration, diuretics, alkalosis, hypokalaemia, GI bleeding) - reduce ammonia concentrations (low protein diet, lactulose, antibiotics) - lactulose retention enema if coma Ascites and oedema - low sodium diet - diuretics (spironolactone first choice, occasionally add furosemide) - paracentesis (drain minimal volume for patient comfort, could worsen bodyside protein status) Haemorrhage and anaemia - vitamin K injections - fresh blood transfusions - B vitamin injections - H2 blockers if GI haemorrhage?