The approach to vomiting Flashcards
Primary vomiting is due to?
Underlying gastric disease
Secondary vomiting is due to?
Non-GI disease
List the causes of focal primary gastric disease
- Chronic gastritis
- Gastric ulcers
- Gastric retention disorders
- Gastric neoplasia
List the causes of diffuse primary gastric disease
- Inflammatory bowel disease
- Diffuse alimentary lymphoma
What clinical sign usually predominates in secondary gastric disease?
Diarrhoea
List some causes of secondary vomiting
- Infections: distemper, lepto
- Pyometra
- Renal failure
- Hepatic disease
- Drugs
- Hypoadrenocorticism
- CNS disease
- Motion sickness
- Vestibular disease
- Neoplasia
Chronic vomiting can occur secondary to which intestinal diseases?
Inflammatory bowel disease
Intestinal neoplasia
Small intestinal obstruction
Pancreatitis
Peritonitis
Other than vomiting, list some other clinical signs of gastric disease
Haematemesis
Nausea/retching
Hypersalivation
Anorexia
Melaena
Bloating
Borborygmi
Weight loss
Describe the pathophysiology of gastric disease
Gastric outflow obstruction
Gastroparesis
Disruption of mucosal barrier
How can the cause of chronic vomiting diagnosed?
- Distinguish vomiting vs. regurgitation
- Eliminate secondary causes: history, physical exam, laboratory analysis, imaging
- Abdominal imaging
- Gastroscopy / coeliotomy
- Symptomatic therapy e.g. anti-emetic
Describe the clinical exam for chronic vomiting cases
- Oral examination: Ulcers
- Abdominal palpation: Pain, Foreign body, intra-abdominal mass, distended stomach or bowel
- Rectal exam, Diarrhoea, Melaena
On clinical pathology in chronic vomiting cases, what can electrolyte levels tell you?
Can tell you information regarding Addison’s
On clinical pathology in chronic vomiting cases, what can haematology tell you?
Inflammatory or not
On clinical pathology in chronic vomiting cases, what can the ACTH stimulation test tell you?
Basal cortisol – if low then do this test. If normal Addison’s can be ruled out
On clinical pathology in chronic vomiting cases, what can the bile acid stimulation test tell you?
Is the liver working as it should?
How is radiography used in chronic vomiting cases? What can be diagnosed?
Survey abdominal radiograph
- Foreign body
- Abdominal mass
- Intestinal obstruction
- Peritonitis
- GDV
How is ultrasound used in chronic vomiting cases? What can be diagnosed?
Foreign body
Ulcers
Thickening of gastric mucosa
Loss of layering (suggests infiltration)
When is endoscopy/gastroscopy indicated in chronic vomiting cases?
If clinical or radiographic signs of gastric disease
What are the causes of chronic gastritis?
Aetiology usually unknown
Sometimes generalised IBD
Various possible reasons
- Chronic gastric parasitism (eg. Physaloptera)
- Hairballs in cats?
- Spiral bacteria - Helicobacter
- Immune-mediated?
What are the most common clinical signs of chronic gastritis?
intermittent chronic vomiting (vague)
± periodic early morning vomit with bile
± poor appetite
How is chronic gastritis diagnosed?
Laboratory changes often non-specific
Imaging findings non specific
Gastroscopy and biopsy
How is chronic gastritis treated?
Removal of aetiologic agent if known
Diet
- Multiple small meals
- Low fat diet
- ‘hypoallergenic’ diet
Acid blocker
Corticosteroids ?
When does bilious vomiting occur?
- Often occurs in dogs fed once daily (especially if fed in the morning)
- Vomiting occurs overnight or in the morning
How is bilious vomiting characterised?
- Vomitus often bile-stained fluid, not food
- Presumably reflects abnormal inter-meal motility allowing bile-reflux into stomach
How is bilious vomiting diagnosed?
Rule out other causes of vomiting
Treatment trial - When patient is not severely ill do this earlier on
How is bilious vomiting treated?
Feed more often, focussing on late meal
You might add prokinetics (ranitidine or metocloperamide) - Sometimes only needed in the evening
Define gastric retention disorders
Retention of food for > 8 hours causing delayed vomiting of food
Why do gastric retention disorders occur?
Anatomical outflow obstruction
Functional disorder
What are the causes of an anatomical outflow obstruction (…which causes gastric retention disorders)?
Pyloric stenosis
Neoplasia, polyp
CHPG = Chronic hypertrophic pylorogastropathy
Foreign body - rubber ball, peach stone, conker, sock
Describe the main features of pyloric stenosis
Congenital in brachycephalic breeds
Association with megaoesophagus in cats
Treatment - pyloromyotomy / pyloroplasty
Describe the main features of Chronic hypertrophic pylorogastropathy
Idiopathic mucosal hypertrophy
May cause outflow obstruction
Most common in toy breeds
May result from hypergastrinaemia ?
Treatment - surgery
What are the causes of a functional outflow obstruction (…which causes gastric retention disorders)?
Primary motility disorder
Inflammatory disease
- Inflammatory bowel disease
- Gastric ulcer
How can you treat the functional causes of gastric retention disorders?
Treat underlying inflammatory disease
Prokinetics
Describe some prokinetic drugs used in function gastric retention disorders
- Metoclopramide - Licensed products exist - Stimulate normal gastric peristalsis
- Ranitidine - H2 antagonist plus prokinetic action
- Erythromycin - Low dose stimulates motilin receptors
List the causes of haematemesis
- Generalised bleeding
- Swallowed blood: Oropharyngeal, Nasal, Pulmonary
- Severe gastritis
- Gastric ulcer
- Gastric neoplasia
- Duodenal disease
List the clinical signs of gastric ulcers
Haematemesis
Melaena
Anaemia
Weight loss
Pain
Peritonitis etc. if perforated
Which posture indicated abdominal pain?
The prayer posture
What is a peptic ulcer?
An ulcer in the stomach or duodenum
Which drugs can cause peptic ulcers?
NSAIDs
Corticosteroids
List some other causes of peptic ulcers
- Head and spinal injuries, in combo with corticosteroids
- Gastritis
- Liver disease
- Uraemia
- Mastocytosis (excess number of mast cells gathering in the body’s tissues)
- Gastrinoma
Name the bacteria that can cause peptic ulcers
Spiral bacteria (Helicobacter)
Name the drugs used to treat gastric ulcers
Sucralfate
Acid blockers – antacids, H2 antagonists, proton pump inhibitors
What is the action of H2 receptor antagonists, name some drug examples used in practice
Block stimulation of HCl secretion
- Cimetidine
- Ranitidine
What is the action of proton pump inhibitors, name some drug examples used in practice
Proton pump inhibitors completely block HCl secretion
Omeprazole (Losec)
Others (pantoprazole, esomeprazole, lansoprazole)
How can you prevent ulcers?
synthetic PGE
misoprostol - antidote to overdose
Describe the triple therpay options for treating Helicobacter
Two antibiotics plus an acid blocker e.g. amoxicillin, metronidazole and omeprazole
OR
3 antibiotics e.g. amoxicillin, metronidazole, clarithromycin
Which animals more common present with gastric neoplasia?
Middle-age/older male dogs > cats
Which gastric neoplasia are most commonly seen in dogs?
Adenocarcinoma (75%)
Lymphoma
Polyps
Leiomyoma / leiomyosarcoma
Which gastric neoplasia are most commonly seen in cats?
Lymphoma
Adenocarcinoma
Describe the effects of gastric adenocarcinomas
Infiltrate gastric wall -> Fibrosis / thickening and ulceration
- Often lesser curvature / distal stomach
- Metastasis to local LN and liver
Gastric adenocarcinomas have a predisposition to which breeds?
Belgian shepherds, Collies, Bull terriers
What clinical signs may lead you to suspect gastric adenocarcinoma?
Suspect in older animal with:
- Chronic vomiting
- Anorexia and weight loss
- Haematemesis and melaena
- Anaemia
- Drooling saliva
How are gastric adenocarcinomas diagnosed?
Contrast radiography
Endoscopic biopsy - often
Full thickness biopsy
How are gastric adenocarcinomas treated?
Surgical resection
Describe the prognosis of gastric adenocarcinomas
grave/hopeless - Probably painful
‘leather-bottle’ stomach
