V+/D+ Flashcards
What are the 6 perfusion parameters?
- Mentation
- Oral mm colour
- CRT
- HR
- Pulse quality
- Extremity temperature
What are the perfusion parameters of severe shock?
- Stuporous
- White-grey mm
- > 3sec CRT
- Tachy/bradycardia
- Non-palpable pulses
- Cold extremities
What are the perfusion parameters of mild shock?
- Obtunded
- Pink-pale mm
- CRT 2 sec
- HR: Tachy
- Good-fair pulse quality
- Normal extremity temp
What are the perfusion parameters of moderate shock?
- Obtunded
- Ppink mm
- 2-3sec CRT
- HR: inc or cats can dec.
- Poor pulse quality
- Cooler extremity temp
What are your 5 hydration parameters?
- Skin tent
- Mm
- Tear film
- Sunken eyes
- Signs of hypovolaemic shock
What are the expected hydration parameters of 5% dehydrations?
- Skin tent <1sec
- MM tacky
- Normal-dec. tear film
- Eyes not sunken
- No shock
What are the expected hydration parameters of 10% dehydrations?
- Skin tent >2sec
- MM dry
- Tear film Dry
- Sunken eyes
- Probably hypovol. shock
What are the expected hydration parameters of 8% dehydration?
- Delayed skin tent
- Tacky mm
- Decreased tear film
- Eyes not sunken
- Possible hypovol. shock
What 6 characteristics are used to differentiate small and large bowel diarrhoea?
- Frequency
- Volume
- Consistency
- Mucus
- Blood
- Tenesmus
What are the features of large bowel diarrhoea?
- Frequency: increased
- Volume: decreased
- Consistency: mucoid
- Mucus: present
- Blood: undigested
- Tenesmus: yes
What are the features of small bowel D+?
- Frequency: normal
- Volume: increased
- Consistency: watery
- Mucus: uncommon
- Blood: digested
- Tenesmus: no
List 10 DDX for primary GIT cause of acute gastroenteritis?
D:
A: idiopathic
M:
N: neoplasia (carcinoma, lymphoma), dietary indiscretion/intolerance
I: inflammatory bowel, GIT parasites, protozoa (giardia), bacterial (Salmonella, Clostridium), viral (parvo, corona), fungal, HE
T: obstruction (FB/intussusception), toxins, gastroduodenal ulceration (NSAIDs, mastocytosis),
V
List 7 DDx for secondary acute gastroenteritis?
D: renal disease (uraemia), hepatobiliary disease
A
M: Addison’s, DKA
N
I: Pyometra, prostatitis, peritonitis, pancreatitis
T
V
What is your main DDx of interest when performing a POC abdominal US: aFast?
to rule out peritonitis (free abdominal fluid)
Why would a serum bile acids or ammonia be performed?
if PSS was suspected
What change in WBC would you see in a puppy with parvo or sepsis?
decreased - as overwhelmed
Indications for faecal PCR
- Diarrhoea >3 d w/out ID cause
2. Concern for false neg. POC parvo test
List 4 bacterial causes of acute gastroenteritis
Clostridia spp, Salmonella spp, E.coli, Campylobacter spp.
What worm and protozoal causes could you rule out through faecal diagnostics?
- Worms: round, hook, whip, tape
2. Protozoa: giardia, coccidia
6 Indications for hospitalisation
- In shock/collapsed
- Protracted vom/diarrhoea (>12h)
- Severe or Haemorrhagic V/D
- Severe abdo pain
- Concern for surgical problem (FB)
- Evidence of systemic illness (fever)
When is a feeding tube indicated?
Place a feeding tube for enteral nutrition if extended period of anorexia (generally >3d): feed despite ongoing vom, regurgitation
Indications to use anti-emetics
- Existing aspiration pneumonia/risk: mentally depressed/exhausted, impaired gag reflex, dyspnoeic for
- Protracted nausea (ptyalism, lip licking)
- Not self-limiting vom
List 3 antiemetics
Maropitant
Ondansetron
Metoclopramide
Indications for antacids
- Reduce gastric acidity
2. Useful if existing gastric ulceration/erosion (haematemesis, endoscopy)
What are two risks of antacids admin?
- Dysbiosis
2. Increase risk of aspiration pneumonia
2 examples of Gastric protectants
sucralfate
barium
4 indications for surgery
- Suspect intestinal obstruction
- Particular rad abnormalities(Gas distended intestinal loops, stacked loops consistent w/ mechanical ileus, Pneumoperitoneum, Pyometra)
- Particular abdominocentesis abnormalities (Septic, suppurative abdominal fluid (intracellular bacteria))
- When all else fails
What are two ‘imitators’ of GIT pain?
- Spinal disease w/ pain (IVDD)
2. Lead poisoning
List the possible body systems to investigate in an acute abdomen case.
- GIT
- Uro-genital
- Spleen
- Hepatobiliary
- Pancreas
- Peritoneum
List 4 DDx for pancreas origin pain
- Acute pancreatitis
- Pancreatic abscess
- Pancreatic infarction
- Neoplasia
List 5 DDx for peritoneum origin pain
D
A
M
N: neoplasia (carcinomatosis)
I: Peritonitis (Septic, Sterile, Sclerosing encapsulating)
T: Herniation esp. secondary strangulation: perineal (spontaneous), inguinal, abdominal wall (w/ trauma), evisceration, penetrating wounds
V
List 5 DDx for splenic pain origin
D: A: M N: neoplasia (HAS, others) *haemoabdomen I: splenitis, splenic abscess T: splenic torsion V: splenic vein thrombosis
List DDx for hepatobiliary pain
D:
A
M
N: hepatobiliary neoplasia
I: acute hepatitis/cholangiohepatitis, Necrotizing cholecystitis, bile peritonitis, hepatic abscess
T: Biliary mucocoele, Gall stones (cholecystoliths) +/- obstuction
V: liver lobe torsion
List 3 radiographic indications for surgery
- GDV
- GIT obstruction
- Septic peritonitis
2 changes to abdominal fluid biochemistry with septic peritonitis
- Low Glucose: BG to fluid glucose different >20mg/dL (glucose will be consumed by bacteria thus will be lower than in blood).
- High Lactate: fluid lactate >2.5mmol/L
What opioids are recommended for acute abdo?
- Fentanyl CRI 2-5ug/kg/hr IV: ideal dt short duration of action, thus easy to titrate
- Methadone 0.1-0.4mg/kg IV (or IM, SC) q4-6hrs
DDx for primary GI disease
D
A: pyloric hypertrophy
M
N: neoplasia - small intestinal lymphoma, adenocarcinoma, MCT
N: nutrition - food responsive enteropathy
I: infections -parasites - toxocara canis/cati, infection w/ helicobacter pylori
I: inflammatory - IBD, lymphocytic plasmacytic gastritis
T: jejunal FB, trichobezoar
V
How does pancreatitis presentation differ between cats and dogs?
In dogs looks a lot like primary GI disease and in cats looks more secondary GI
Cats w/ hyperthyroidism can look..
like they have primary GI disease; intermittent V+ over long periods and otherwise well
EPI can look like
primary GI disease
7 signs to pursue diagnostics
- V+ severe and persistent (>2wks)
- No or incomplete response to symptomatic therapy
- Animal regurgitating
- Can palpate GI abnormality
- Other systemic signs are present eg. PU/PD, icterus
- Animal appears systemically unwell
- Systemic signs clearly preceded the V+
tests for pancreatitis
pancreatic lipase immunoreactivity (cPLI, fPLI)
CBC
Abdo US
tests for liver disease
ALT, ALP, GGT, bilirubin, bile acids
Abdo US
Azotaemia parameters
BUN, creatinine, phosphate, USG
investigating DKA
blood and urine glucose + ketones
investigating hypercalcaemia
serum calcium - total and ionised
investigation hypoA
Na+, K+, baseline cortisol, ACTH stim. test
investigating hyperthyroidism in cats
total T4
clear bile suggestive of?
stomach issue
yellow/green bile suggestive of?
duodenum
brown, fetid, large volume vomit suggests?
intestinal obstruction
‘coffee grounds’/haematemesis suggests
ulceration/neoplasia
vom of a meal >12hrs after ingestion suggests
delayed gastric emptying
Primary small intestinal GIT dz DDx
D
A: antimicrobial responsive enteropathy, food responsive enteropathy
M:
N: neoplasia
I: inflam/infiltrative, parasites (ancylostoma caninum, toxocara canis/cati), giardiasis, salmonella
T: obstruction
V:
Primary large intestinal GIT dz DDx
D A: M N: neoplasia, diet related I: inflam/infiltrative lymphocytic plasmacytic colitis, parasites trichuris vulpis (whip), tritrichomonas (cats), clostridia, campylobacter T: obstruction (bone fragments) V:
Tests for secondary GI causes of diarrhoea (primarily small bowel)
- Trypsin-like immunoreactivity (TLI) to rule out EPI
- Liver disease - ALT, ALP, GGT, Bilirubin, Bile acids, Abdo US
- HypoA - Na+, K+, baseline cortisol, ACTH stim
- HyperT (cats) - total T4
- Toxaemia - CBC
3 GI helminths
toxocara, ancylostoma, trichuris
1 cat and 1 dog GI enteric protozoa
dog - giardia
cat - tritrichomonas
there is a faecal snap test for which enteric protozoa?
giardia (Idexx)
tx for giardia
fenbendazole, drontal plus for 3d
what info do you gain by investigation folate and cobalamin serum levels?
- decreased cobalamin –> EPI, bacterial dysbiosis, ileal dz, + common in cats w/ IBD
- decreased folate –> prox. SI dz
- inc. folate –> bacterial dysbiosis w/ EPI
empirical anti-parasitic treatment
- pyrantel or equivalent plus praziquantel OR
2. fenbendazole trial
duration of dietary trial for possible food response enteropathy?
2-4weeks
empirical tx of SI D+ (for antibiotic responsive enteropathy)
- Tylosin 20mg/kg q12h PO 4-8wks
2. Metronidazole 10-15mg/kg PO BID
3 indications that you should biopsy the GIT
- Severely affected w/ systemic manifestations (anorexia)
- Presence of hypoalbuminaemia, hypoglobulinaemia suggests a PLE
- Abnormalities on abdo US - changes to GI wall layers
Gastric/intestinal biopsies are necessary to provide a dx for which (5) dz?
- gastritis (diff. types)
- IBD (colitis - endoscopy)
- Infiltrative dz; neoplasia, fungal (histoplasmosis)
- lymphagiectasia in SI
- Breed-assoc. enteropathies
benefits of endoscopic biopsies
- minimally invasive
- direct visualisation of oesophagus, stomach, prox duodenum, colon + ileum
what can you not reach via endoscope?
jejunum
3 indications for lap. surgical biopsy
- endoscopic biopsy not avail
- focal dz in mid-intestine suspected
- if more widespread intra-abdo disease (cats!!)
what is the complication rate of lap. sx biopsies?
20% - wound breakdown, septic peritonitis
advantages of surgical biopsy
- Evaluate entire abdo
- can target areas that look abnormal
- can sample all SI
- full thickness biopsies
Disadvantages of surgical biopsies
- morbidity of ex lap
- concern in hypoalbuminaemic dogs
- higher risk of dehiscence thatn w/ endoscopy
tritrichomonas causes?
chronic large bowel D+ in cats
Trichuris can mimic..
hypoA - causes large bowel D+
Ancylostoma causes…
anaemia, small bowel D+ in dogs
Toxocara canis/cati causes…
ill-thrift, pot belly, V+, small bowel D+
melena is a sign of…
high GI bleeding (gastric/duodenal ulceration/neoplasia)
causes of local ulcerative GI dx and haematemesis
D: IBD - lymphocytic plasmacytic infiltrate A: NSAIDs, corticosteroids M N: neoplasia - gastric carcinoma I: Helicobacter infection, gastritis T: gastric FB V
systemic causes of haematemesis
- renal failure (uraemia)
- pancreatitis
- hypoA
- liver failure (rare)
- hyperacidity - gastrinoma, MCT
- haemostatic disorder
5 parts of haematemesis tx
- Hospitalisation + investigation
- ID and Tx primary cause
- IVFT
- PPIs - pantoprazole IV, omeprazole PO
- Gastric protectants - sucralfate 1g/dose q12h PO
DDX for gastric dysmotility and delayed emptying
- gastric +/- pyloric hypertrophy –> pyloric stenosis
- gastric neoplasia
- FB in stomach (or lodged in pylorus)
- compression of the pylorus by external masses (eg. liver, neoplasia)
- can see w/ chronic gastritis/ IBD
3 histological classifications of IBD
- lymphocytic-plasmacytic enteritis (LPE)
- eosinophilic enterocolitis
- granulomatous enterocolitis
CS of IBD
- rel to anatomical location; vom (cats), anorexia, weight loss, chronic/small bowel d+ (dogs)
- abdo pain, intestinal bleeding, borborygmus
+/- oedema/effusions
what are oedema and effusions associated with IBD?
protein loss - secondary lymphangiectasia
what is often assoc. w/ IBD in cats?
often assoc. w/ other lymphocytic-plasmacytic inflammation
ie. cholangiohepatitis + pancreatitis
Triaditis
what may IBD in cats progress to?
may co-exist or progress to intestinal small cell lymphoma
how do dog and cat presentations of IBD differ?
cats vom and dogs shit
what is your first step in tx IBD in dogs?
Dietary trial ‘hypoallergenic’
- should see response in 2wks
what tx do you trial after diet in canine IBD?
antimicrobials –> tylosin, metronidazole
You have trialed a hypoallergenic diet and tylosin in a dog with IBD with no response – what are you next plans of action?
- Immunosuppressives: prednisolone 1-2mg/kg q12h PO x14d tapering over time.
+/- azathioprine, cyclosporine (if poor response or BIG doggo to reduce pred dose)
how does your treatment of feline and canine IBD differ?
- Both have the dietary trial first but cats don’t trial antimicrobials –> straight to immunosuppressives.
- Cats also NEVER add azathioprine, use chlorambucil instead.
- Also add cobalamin (Vit.B12) in cats
What grading is used with GIT lymphoma?
- Low grade = small cell
- Medium -grade = lymphoblastic
- high-grade = B-cell > T-cell
how can you differentiate low-grade alimentary lymphoma in cats from IBD?
req. combo of morphological and immuno-phenotyping techniques +/- PCR
Tx of low grade alimentary lymphoma (LGAL) in cats
- pred + chlorambucil
what are boxers predisposed to re. large bowel diarrhoea
histiocytic colitis
What are your 3 empirical therapies for dogs w/ large bowel diarrhoea + tenesmus?
- Fenbendazole 50mg/kg q24h 3-5d
- Feed: novel protein for 4-6wks
- Add soluble fibre - metamucil 1tsp/5kg/meal
CS of histiocytic ulcerative colitis in boxers
- severe large bowel signs: profound weight loss and severe haematochezia
tx. of granulomatous histiocytic ulcerative colitis
enrofloxacin 10mg/kg q24h PO 8-12wks
mild constipation tx
- microlax enema
- warm water/saline enema w/ lubricant
* always follow up and ensure that defaecation occurs
Describe process of deobstipation
manual removal of faeces w/ the animal under GA often necessary after rehydration. All obstipated animals, broad spec antimicrobials for possible bacteraemia, initial enema (water lubricant) to begin faecal softening. GA w/ ETT (huge risk of aspiration), warm saline enema w/ lubricant jelly via soft feeding tube/10 French urinary catheter into the colon. Mannual breakdown of faeces by transbadominal massage/instruments. Remove fragments via anus. Rads to document success.
long-term medical management recurrent constipation
- Removal or inciting causes (drugs, bones, concurrent disease)
- Dietary manipulation, laxatives and prokinetics (lactulose syrup, polyethylene glycol and cisapride (compounded) most common drugs for megacolon)
indications for subtotal colectomy
w/ recurring obstipation that responds poorly to exhaustive medical therapy.
highest incidence of acute pancreatitis occurs in…
middle-aged, obese, sedentary female dogs
US findings of acute pancreatitis
pancreatic enlargement, changes in echodensity, hyperechoic abdominal fat
treatment of acute pancreatitis (dogs)
- feed as soon as V+ subsides - tubes/freq.small meals of high-CHO restricted fat
- Parenteral fluids
- anti-emetics + prokinetics
- pain relief
- antimicrobials in severe cases (septic/abscess) - enrofloxacin, amoxiclav
**long term restricted fat diet
possible sequelae to acute pancreatitis
- chronic recurrent pancreatitis
- EPI
- DM
CS w/ pancreatitis in cats
usually non-specific: anorexia, lethargy +/- fever/hypothermia, weight loss, vom, abdo pan often absent, may deteriorate signs of shock w/ acute form.
treatment of acute pancreatitis in cats
- IVFT + lytes
- Feeding: tube + antiemetics
- Broad-ABs if indicates
- Dx/tx concurrent disease ie. triaditis
what is EPI?
failure of pancreatic acini to produce enzymes and bicarbonate
Pancreatic acinar atrophy is classically seen in what dog breed?
german shepherd
CS of EPI
i. Voluminous SI diarrhoea: but can be just increased faecal bulk
ii. Weight loss, poor hair coat
iii. Ravenous appetite
DX of EPI
serum TLI (fasted!)
4 arms of management of EPI
- Pancreatic enzyme supplement
- Restricted fat diet, feed smaller meals 2-3x daily
- Cobalamin supp
- Control bacterial dysbiosis which can complicate EPI
what is the most common cause of maldigestion?
EPI
But can also see w/ loss or impaired bile salt activity dt ileal/liver disease
how does maldigestion affect appetite?
normal to greatly increased
give an example of disruption to luminal absorption…
dysmotility in hyperthyroidism resulting in malabsorption
give an example of disruption to mucosal absorption…
deficiency of brush border or enterocyte defects secondary to IBD
give an example of disruption to transport absorption…
lymphatic obstruction – primary lymphangiectasia or lymphagiectasia secondary to IBD or neoplasia
how can right sided congestive heart failure cause malabsorption?
portal hypertension
what are the major secondary causes of malabsorption?
- hyperT
2. liver disease (can cause maldigestion dt lack of bile salts and malabsorption dt portal hypertension)
is diarrhoea usually a feature of malutilisation?
no
what are some possible causative conditions of malutilisation?
- diabetes mellitus
- congestive heart failure
- hyperT
- neoplasia (cachectin…)
give an congenital cause of PLE
congenital lymphangiectasia
give 2 acquired causes of PLE
severe IBD, intestinal neoplasia (lymphoma)
4 ddx for hypoalbuminaemia
- reduced production: chronic liver disease, malassimilation
- increased loss; haemorrhage, PLE, severe exudative skin disease
which protein in lost via glomerular disease?
albumin only
4 ddx for hypoglobulinaemia
- failure of colostral transfer (foals)
- immunodeficiencies dz (rare)
- globulins lost w/ albumin (haemorrhage, PLEs, severe exudative skin dz)
list 3 important diagnostics to rule out extra GIT causes of hypoalbuminaemia
- check urine for protein loss (urine protein:creatinine >2)
- check liver function - bile acids stim. test
- check PCV to look for evidence of haemorrhage
