Vomiting

Question 1

Diagnostic approach to vomiting patient

Answer 1

Define the problem, system, location and lesion

Question 2

Defining the problem

Answer 2

Either vomiting, regurgitation, gagging, coughing, reflux

Question 3

Physiology of vomiting

Answer 3

Coordinated response
The emetic reflex includes visceral receptors, vagal and sympathetic afferent neurons, CRTZ, vomiting center in the reticular formation of medulla oblongata

Question 4

Nausea

Answer 4

Reduced gastric tone
Duodenal and proximal jejunal tone ↑
Duodenal contents reflux into stomach
Depression, hypersalivation, repeated swallowing

Question 5

Vomiting

Answer 5

Glottis closed
Soft palate pressed up against nasopharynx (protects against aspiration)
Abdominal muscles and diaphragm contract
Cardia opens, pyloris contracts
Reverse peristalsis
Cardiac rhythm disturbances
Changes in colonic motility

Question 6

Regurgitation

Answer 6

Passive process
Induced by alteration in food consistency and exercise
Facilitated by gravity when head/ neck down

Question 7

Characteristics of regurgitation

Answer 7

Undigested food
Mucus when esophagus irritated
Cough (concurrent aspirated pneumonia)

Question 8

Vomiting can be treated ____________

Answer 8

Symptomatically

Question 9

Useful tests for vomiting

Answer 9

Biochemistry
Haematology
Urinalysis
Abdominal imaging
Endoscopy
Exploratory laparotomy

Question 10

Investigating regurgitation

Answer 10

Usually a bad disease
Images of the esophagus (rads, contrast, fluoroscopy)
Endoscopy

Question 11

Defining the system

Answer 11

Primary GI disease or Secondary GI disease

Question 12

Primary GI (structural)

Answer 12

Stomach to the colon (surgical or medical problem)

Question 13

Secondary GI (functional)

Answer 13

Accessory digestive organ (Pancreas, liver)
Electrolyte imbalance (K+, Na+, Ca2+)
Endogenous toxins (kidney, liver, ketoacidosis, infection)
Exogenous toxins
Primary CNS

Question 14

Tests to investigate secondary GI disease

Answer 14

Haematology
Urinalysis
Exploratory laparotomy

Question 15

Tests to investigate primary GI disease

Answer 15

Abdominal imaging
Endoscopy
Exploratory laparotomy

Question 16

Vomiting from primary GI disease

Answer 16

Relates in time to eating
Delayed for some hrs with non-imflamm gastric disorders
Foreign bodies or secretory disorders (not eating)
Occurs after eating in lower bowl disorders

Question 17

Evidence of primary GI disease

Answer 17

Abnormality palpable in the gut
Vomiting with diarrhea
Norm. in other aspects
Vomiting B4 signs of malaise
Vomiting related to eating

Question 18

Evidence of secondary GI disease

Answer 18

Vomit after signs of malaise
Other clinical signs present
Patients metabolically ill (except pancreatitis and hyperthyroid in cats)

Question 19

Primary diseases of the stomach

Answer 19

Gastritis, gastric foreign bodies, gastric ulceration, disorders of the pylorus, abnormal gut motility

Question 20

Primary diseases of the intestine

Answer 20

Enteritis (parvo, carona, garbage), intestinal obstruction, IBD, neoplasia

Question 21

Secondary GI causes of vomiting

Answer 21

Pancreatitis, liver, renal and endocrine disease (diabetic ketoacidosis, hypoadrenocorticism, hypercalcemia)

Question 22

What if the patient is regurgitating?

Answer 22

Define location b4 system (esophagus primary disease)
Define lesion b4 system

Question 23

Anatomic esophageal disorders

Answer 23

Cricopharyngeal disease
Hiatal hernia
Diverticulum

Question 24

Megaesophagus

Answer 24

Congenital
Acquired- primary (idiopathic) or secondary (systemic causes like MG and hypoadrenocorticism)

Question 25

External compression (esophageal disorders)

Answer 25

Persistent right aortic arch
Mediastinal lyphoma
Thyroid tumors

Question 26

When is symptomatic therapy appropriate?

Answer 26

Patient has primary GI disease due to toxin or dietary indiscretion
Mild pancreatitis

Question 27

When is symptomatic therapy not enough?

Answer 27

No response to symptomatic therapy
Vomiting persistant an severe
Other CS suggesting secondary GI disease (jaundice, PU/PD, anemia)