Veterinary Medicine - Gastrointestinal Diseases Flashcards
Clinical signs esophageal diseases? Also - name the clinical signs expected if complications occur (2 specific complications of esophageal diseases)
Regurgitations
Hypersalivation
Sialoadenosis
Gagging
Aspiration pneumonia: Fever, Lethargy, Anorexia, Tachypnea, Dyspnea, Cough
Nasopharyngitis +/- Nasopharyngeal stenosis: Reverse sneezing, Sneezing, Stridor, Stertor.
Oro-pharyngeal Vs. esophageal disease - Name one hallmark clinical sign for each
Oro-pharynx - Dysphagia
Esophagus - Regurgitations
What in the neurological exam can give a hint to Myasthenia Gravis?
Progressively weakening palpebral reflex
Regurgitations Vs. Vomiting: Pharynx/Esophagus/Stomach - Pain on swallowing
Possible
Frequent
No
Regurgitations Vs. Vomiting: Pharynx/Esophagus/Stomach - Ejection period after meal
Immediate
Immediate / Delayed
Delayed
Regurgitations Vs. Vomiting: Pharynx/Esophagus/Stomach - Qualities of ejected food (Digested / Undigested, Color)
Undigested, Colorless
Mostly undigested. Can be partially digested. Mostly colorless, Yellowish-greenish color also possible (more commonly associated with gastric content but not limited to)
Digested. Yellowish-greenish color (Bile)
Regurgitations Vs. Vomiting: Pharynx/Esophagus/Stomach - Ability to drink (Poor / Normal)
Poor
Normal
Normal
Regurgitations Vs. Vomiting Pharynx/Esophagus/Stomach - Swallowing attempts (Single/Multiple)
Multiple
Single
Single
Regurgitations Vs. Vomiting: Pharynx/Esophagus/Stomach - Commonly associated with secondarily causing dyspnea and coughing due to Aspiration Pneumonia
Yes
Yes
No
Reflux of food content from the stomach to the esophagus is always abnormal (True/False)
False
Normal healthy dogs can regurgitate from time to time as seen in fluoroscopic studies of the lower esophageal sphincter
Assessment & Diagnosis of Dysphagia - Physical examination / additional diagnostics
Full PE (emphasis on Initial oro-pharyngeal exam, sialoadenosis, masses, chest auscultation for signs of aspiration pneumonia)
Neurological assessment (with emphasis on cranial nerves, muscle symmetry, palpebral, swallow reflex, tongue motility)
Eating/drinking test (If not scheduled for anesthesia)
Full biochem panel (with emphasis on clues for endocrinopathies/CK levels/additionally - Cholinesterase levels, AB titers for MG)
Full oro-pharyngeal examination under sedation
Imaging: X-Ray / Fluoroscopy (Swallow study) / Endoscopy.
Pharyngeal dysphagia - Mechanical problems (DDs)
Pharyngitis: Viral (e.g. Calicivirus, Herpes), Bacterial, due to reflux
Corrosive agents
Masses (e.g. Granuloma, Abscess,
Neoplasia, Polyp, Cyst)
Sialoadenosis
Anatomical defects: Hypoplasia/Hyperplasia of soft palate
Misc. Stricture, Foreign body, Trauma
Pharyngeal dysphagia - Functional Problems (DDs)
Neurological (CNS/PNS diseases)
Junctionopathies (e.g. Myasthenia Gravis, Organic Phosphate (Chronic), Botulism)
Muscles: Myositis (Immune, Infectious, Pre-neoplastic), Muscle dystrophy, Storage diseases, Hypothyroidism
Cricopharyngeal Achalasia
Cricopharyngeal Asynchrony
Cricopharyngeal Achalasia - Treatment (2 options)
Botox injection (Short term)
Myotomy of Cricopharyngeal m.
Cricopharyngeal Asynchrony - Treatment
Conservative treatment:
-Find the food with the best texture for this specific dog
-High frequency + small quantities of food each time
-Bailey’s Chair
Esophagitis - DDs
Pill esophagitis (e.g. Doxycycline)
Reflux esophagitis (e.g. Anesthesia, 2nd to BAOS, Certain drugs)
Ingestion of caustic material
Foreign Body
Chronic Vomiting
Granuloma/Neoplasia/Inflammation involving the LES.
Reflux esophagitis (DDs)
Drugs (e.g. Anesthesia, Atropine, Anti-histamines)
Hiatal hernia
Due to upper respiratory disease (BAOS, Nasopharyngeal disease)
Coughing
Sialoadenosis - A Clinical sign / PE finding that is usually suggestive of pathology in what organ?
Esophagitis
Esophagitis - Clinical signs. Also, try to think of complications and their respective clinical signs
Mild cases - only regurgitations
Severe inflammation: Anorexia, Fever, Regurgitations, Pain on swallowing, Weight loss, Hypersalivation, Sialoadenosis
Signs of aspiration pneumonia: Fever, Cough, Dyspnea
Signs of anemia: Melena, pale mucus membranes, weakness
What is a common intra-mural sequela of esophagitis?
Stricture
Esophagitis - Treatment
Treat underlying issue
Switch to small portions + High frequency feedings
Low fat diet
Feed from above with neck extended (can use Baileys chair)
GI Protectants (Sucralfate, PPI), Pro-Motile (Metoclopramide)
Analgesia
*Gastric tube in severe cases
Sucralfate - Important thing to remember if additional drugs are also meant to be administered with it
Sucralfate can interfere with the absorption of other drugs. When giving sucralfate - separate from food and other drugs 2 hours before and after administration.
H2 Receptor blockers - Most relevant drug of the family? How long does it remain effective?
Famotidine
24-48 Hours
Proton pump inhibitors (PPI’s) - Relevant drugs, what are 2 Important points to remember with long term usage?
Omeprazole/Omepradex/Pantoprazole
1) After 4 weeks - Taper off slowly to avoid massive resurgence of acid production
2) Can cause dysbiosis
Pro-motile drugs - Names, Effects and which is considered a more effective pro motile drug?
Metoclopramide (Pramin) - Constricts LES, Promotes stomach contractility, Anti-Emetic
Cisapride (Preplusid) - Constricts LES, Promotes contractility along the entire GI tract (except for the esophageal striated muscle)
Cisapride > Metoclopramide
Mechanical causes for regurgitations (Esophagus) - The 3 main categories are:
Intra-luminal
Intra-mural
Peri-esophageal (Extra-esophageal)
Mechanical causes for regurgitations (Esophagus) - Intraluminal - DDs
Foreign body
Esophageal foreign body - Diagnosis & Treatment
History and clinical signs
Chest X-rays
Endoscopy (Gold standard)
Removal via endoscopy is best. If not possible - pushing the foreign body to the stomach and removal via surgery is also a possibility
+/- Treatment for esophagitis
Esophageal stricture - Causes
Caustic agents
Esophagitis
Surgery
Foreign Body
Luminal or Peri-Esophageal masses
Esophageal Stricture - Diagnosis
Endoscopy
Swallow study via Fluoroscopy
Esophageal stricture - Treatment
Bougienage (Balloon dilatation) + Short course of GC (to prevent inflammation and recurrence)
Stent (in the event of recurrence)
Surgery
+ Gastric tube and treatment for esophagitis
Mechanical causes for regurgitations (Esophagus) - Intramural - DDs
Esophagitis
Stricture
S.Lupi (In relevant countries)
Neoplasia
Diverticulum
S.Lupi (Esophageal) - Diagnosis
History (Mainly lack of preventative treatment) and clinical signs
Chest X-rays:
-Soft tissue opacity in the caudal mediastinum (caudal third of esophagus)
-Aortic mineralization and aneurism
-Spondylitis (T6-T12)
Fecal analysis
Endoscopy (Gold standard) - Typical appearance of S.Lupi granuloma - Smooth bulge continuous with the esophageal wall
S.Lupi (Esophageal) - Atypical presentations
Migration through the CNS (causing paresis/plegia)
Migration through Mesenteric arteries - Ischemia to GI and necrosis. Can cause either septic peritonitis or Hemoabdomen
Cutaneous fistula
Aortic rupture - Acute collapse & hemothorax (Acute death).
Esophageal neoplasia - Common types and locations (intra-mural / Peri-esophageal masses that can lead to regurgitations)
Intra-mural: Carcinomas (Cats), Sarcomas (S.Lupi), Leiomyoma
Peri-Esophageal: Thymoma, Chemodectoma
Esophageal neoplasia - Treatment & Prognosis
Surgery / Laser
Excellent if on a thin stock
Esophageal Diverticula - Diagnosis
Contrast study
Endoscopy
Mechanical causes for regurgitations (Esophagus) - Peri-esophageal - DDs
Vascular ring anomalies (e.g. PRAA)
GI accidents (e.g. Sliding hiatal hernia, Gastro-esophageal intussusception)
Mediastinitis
Intra-thoracic neoplasia (e.g. Pulmonary neoplasm, Heart-base tumor)
Severe lymphadenopathy
Persistent right aortic arch (PRAA) - Diagnosis
Classic history - regurgitations begin upon weaning and switching to solid foods (puppyhood)
Chest X-rays +/- Contrast study
CT
Persistent right aortic arch (PRAA) - Common complications (2)
Growth retardation (with good appetite)
Aspiration pneumonia (Cough, Fever, Dyspnea)
Hiatal hernia - Signalment
Congenital - Brachycephalic breeds over-represented
Acquired: 2nd to upper respiratory tract diseases (Nasopharynx in particular), Trauma with damage to the diaphragm
Hiatal Hernia - Clinical signs
Esophagitis - Regurgitations, Melena, Hypersalivation, Sialoadenosis
Fever and anemia in severe cases
Aspiration pneumonia (Fever, Dyspnea, Cough).
Hiatal Hernia - Diagnosis
Chest X-rays: Soft tissue opacity in the caudal mediastinum (caudal third of esophagus)
False negative rates high with sliding hiatal hernia and do not rule out the disease
Endoscopy (J-Maneuver)
Fluoroscopy
Hiatal Hernia - Treatment
Treat Reflux Esophagitis (PPI, Protectants, Pro-Motiles)
Treat Respiratory Disease (Surgery for Brachycephalic)
Last Resort - Gastropexy
Megaesophagus - Most Common: Congenital/ Acquired
Acquired
Megaesophagus - 2 Most common causes for acquired megaesophagus?
1) Idiopathic
2) Myasthenia Gravis
Megaesophagus - Congenital - Most commonly affected breed
German Shepard
Megaesophagus - Congenital - Classic presentation /Clinical signs. Also, What is another major DD?
Regurgitations from weaning
Aspiration pneumonia
Growth retardation
Vascular ring anomalies (e.g. PRAA)
Megaesophagus - Acquired - DDs
Idiopathic
Neuropathies: (e.g. Inflammation, vascular, Neoplasia) mainly involving the Vagus nerve CN9 (CNS/PNS)
Junctionopathies: Organic phosphates (Chronic), Myasthenia Gravis, Botulism, Tetanus
Muscles: Myositis, Dermatomyositis, Muscle Dystrophy, Storage Diseases
Led Poisoning
Endocrinopathies: Addison’s disease, Hypothyroidism
Chronic distal impaction: Foreign body, LES achalasia
Megaesophagus - Diagnosis
Full history & PE
Full neurological exam (with emphasis on medullary CNs)
Chest X-rays (Diagnosis of megaesophagus is usually achieved via X-rays)
CBC, Panel, UA (Aspiration Pneumonia, CK, Clues for Endocrinopathies, Basal cortisol, T4)
Fluoroscopy + Swallow study (When not obvious on X-rays)
ACh Anti-body titer / Tensilon test (If other clinical signs of Myasthenia Gravis are present
Megaesophagus - Treatment & Prognosis
-Treat underlying cause if possible (And then full remission is also possible)
-High frequency/Small quantities feedings
- food with appropriate texture for the dog (based on trial & error)
-Feed from above so neck is extended upward. Can use a Baileys Chair
-Gastric tube (last resort)
-Treat episodes of aspiration pneumonia
Prognosis: Mostly poor in the long run but depends on the primary cause.
Stomach - What are the 4 main defense mechanisms against acidity
Tight epithelium
Mucosal barrier with HCO3-
Vast blood supply to the mucosa
PGE2 (Promotes the former three)
Stomach - Helicobacter can be part of the normal flora in cats and dogs (T/F)
True
Stomach - 2 Causes for stomach-originating dysbiosis
Atrophy of the stomach glands due to chronic disease
Prolonged use of anti-acids (e.g. PPIs)
Gastric disease - Clinical signs
Vomiting
Retching
Hematemesis
Melena, Burping
Nausea, Hypersalivation
Tympany
Abdominal pain
Weight loss (Chronic)
Vomiting - What questions are important to ask the owners?
First! Differentiate between vomiting and regurgitations! Different set of DDs:
-Content digested/undigested
-How long does it occur in relation to meal time
-Color/colorless
-Abdominal contraction y/n (the biggest differentiating sign)
-Blood?
-Volume?
-Frequency?
-When did it start?
-Vaccinated?
-What does he eat?
-Has access to the outside?
-Other clinical signs?
Vomiting - Intra-GI - DDs
Food: Garbage intoxication, dietary indiscretion, Intolerance
Inflammation: Infectious (e.g. Parvovirus, Distemper, Giardiasis)/Non-Infectious (e.g. Chronic inflammatory enteropathies)
Gastric ulcers
GI Accidents (e.g. Foreign body, Intussusception)
Neoplasia
Bilious vomiting
Vomiting - Extra-GI - DDs
-Hepatopathies
-Nephropathies (e.g. AKI, CKD)
-Pancreatitis
-Biliary tract disease
-Endocrinopathies (Addison’s disease, DKA, Hyperthyroidism)
-Abdominal disease (e.g. Peritonitis)
-Vestibular Disease
-Drugs\Toxins (e.g. Organic phosphates, Apomorphine)
-Shock, Sepsis, SIRS, Endotoxemia
-Electrolytes/Acid-Base Disorders
Vomiting - Treatment
Treat underlying cause
Correction of fluids, electrolytes
Anti-Emetics (e.g. Maropitant, Ondansetron, Metoclopromide)
GI-Protectants in case of ulcers (e.g. PPI)
Analgesia (if indicated)
Change of diet (e.g. low fat, tuna, rice, hypoallergenic). Can either be for a few days or for an extended period of time depending on the etiology
Anti-emetics - Name the main drugs (3)
Metoclopramide
Maropitant
Ondansetron
Metoclopramide - 2 Contraindications
GI accidents (e.g. Foreign body, Intussusception)
GI Bleeding (Can interfere with clot formation
Cerenia - In addition to being an effective anti-emetic, what is the drugs added effect and through what mechanism?
Analgesia (Substance P blocker through NK-1 Receptor)
GI Protectants - Name the main drugs
Anti-acids: H2 Blockers (e.g. Famotidine)
PPI (e.g. Omepradex)
Adsorbents: Sucralfate
PGE2: Misoprostol (Cytotec)
Describe the diet aspect in treating a simple acute case of gastritis and vomiting (Types of food and general composition)
Switch to easily digestable diet for 5-7 days - High in carbs, moderate protein, low fat & low fibers. Can switch to commercial diet or home made (e.g. rice, chicken, tuna). Switch back to previous food gradually over the course of 3-4 days
Usually acute gastritis is diagnosed tentatively from history and clinical signs. What would make you want to go further with additional diagnostics?
Hematemesis
Systemic clinical signs
Which specific glucocorticoid is most notorious for causing gastric ulcers
Dexamethasone
Gastric ulcers - General categories of causes (4)
Acid over-production
Decreased perfusion
Direct damage to the mucosa
Decreased prostaglandin production
Gastric ulcers - causes
Acid over-production: Kidney failure (Gastrin, uremia), Liver failure (Gastrin), Neoplasia such as MCT (Histamine), Gastrinoma
Damage to the mucosa: Foreign body, Gastritis, Pancreatitis, neoplasia (e.g. Leiomyoma)
Decreased perfusion: Addison’s disease Sepsis, SIRS, DIC, Shock
Decreased PGE production: NSAIDs > Steroids
Misc. Stress-related mucosal disease, Ulcers of working dogs.
Gastric ulcers - Clinical signs
Vomiting
Hematemesis, Melena
Abdominal pain
Pale mucus membranes (severe cases)
Gastric ulcers - NSAIDs - Typical anatomical location of gastric ulcers
Antrum
Gastric Ulcers - Treatment
Treat underlying cause
Fluids, Electrolytes, Colloids (in cases of severe hypoproteinemia)
GI-Protectants (e.g. PPIs, Famotidine, Sucralfate, Misoprostol in case of NSAIDs-derived ulcers)
Anti-emetics (e.g. Maropitant, Ondansetron, Metoclopramide)
Analgesia (e.g. Buprenorphine, Butorphanol, Tramadol)
Antibiotics (If indicated)
*Surgery in specific cases (Neoplasia, Perforation)
Chronic gastritis - DDs
Chronic inflammatory enteropathies
Chronic foreign body (Rare but possible)
Hypertrophic gastritis
Atrophic gastritis
Helicobacter (Controversial)
Helicobacter - Considered always a cause of disease (T/F)
False
Found in 40-100% of both clinical and non clinical dogs and cats
Helicobacter - Same Isolates as Humans (T/F)
False