Vomiting Flashcards
how can you rule out obstructive disease in vomiting?
History:
* Always ask about scavenging/foreign bodies/diet e.g. bones.
* Diarrhoea in puppies/kittens
◦ Intussusception is more likely
◦ Or worms – check worming status, or pre-emptively worm them if concerned.
* BCS – condition loss is a concern for more chronic disease
* Faecal output – if normal then obstruction is less likely.
* Other signs of disease e.g. PUPD
Clinical signs:
* Abdominal palpation – pain or can you feel a swelling of the GIT?
◦ Faeces in the colon can trick you in cats – i.e. it’s constipated e.g. dehydration in renal failure.
* Signs of sepsis/hypovolaemia - (perforation)
* Mentation – dullness/lethargy/obtunded/stuporous – treat them all as serious (perforation)
POCUS
* Free fluid in the abdomen is always abnormal
* Perforating foreign body
* May be able to directly image what you can feel – e.g. intussusception
Raidology (+/- contrast)
what should you do if you have a vomiting patient and they seem fine and you don’t think they have obstructive disease?
- Symptomatic treatment is acceptable
- Most episodes of gastritis, gastroenteritis, dietary indiscretion, intolerance are self-limiting.
- Dietary modification/support – Gastrointestinal Diet.
◦ High bioavailability of protein
◦ Easily digestible Carbohydrate and fat
◦ Low fibre (both slow gastric emptying) - Gastro-protectants and anti-emetics
What should you do if you think its non-obstructive but they are not getting better?
Acute, none-responsive to symptomatic treatment:
* You might be wrong!! Consider obstructive again – re-evaluate.
* Are other clinical signs developing:
*
* Diarrhoea/changes in faecal output
◦ Consider faecal samples for bacterial, viral, parasitic disease
◦ (See diarrhoea lectures)
* PUPD/changes in urination/drinking
◦ Biochemistry to assess for renal or hepatic disease e.g. Acute Kidney Injury
* Neurological signs
◦ Cranial nerve deficits/changes in vision -> cerebral disease
◦ Ataxia/head tilt -> vestibular system (check the ears)
* Pyrexia
◦ Look for the infectious/inflammatory focus -> POCUS, haematology, biochemistry
- Specific Tests:
◦ T4 for hyperT4 in cats
◦ cPLI and fPLI – pancreatitis
◦ Electrolytes and acid/base – may be developing hypochloremic alkalosis (vomiting up acid, therefore losing chloride) – will need IVFT support
‣ can be a sign of pyloric obstruction - need to look for this
◦ Basal Cortisol - Addisons
What should you do if you have a chronically vomiting animals and are losing weight?
- Check the patients BCS and weight history
- Owners need to be ‘on boarded’ to investigate – symptomatic treatment is no longer appropriate.
- Consider everything on the last slide, but now also think about:
- Diarrhoea/changes in faecal output
◦ Chronic enteropathies
‣ Endoscopy and biopsies/food trials/infectious disease screening - PUPD/changes in urination/drinking
◦ Chronic hepatic, renal or endocrine disease - Neoplasia
◦ Adenocarcinoma
◦ Leiomyosarcoma and GIST
◦ Lymphoma
◦ Polyps - Chronic Pancreatitis
how do you diagnose neoplasia in vomiting dogs?
Diagnosis requires biopsy
* Full thickness is the most reliable.
* Endoscopic biopsies are superficial and may miss lesions.
* Ultrasound is not as sensitive as endoscopy at identifying abnormal tissue for FNA/biopsy
* Surgical biopsy is the most sensitive.
* Always do a met check (3 view CXR or CT), although intestinal neoplasms less commonly spread to the lungs.
what is the most common tumour of the stomach and large intestine, that is also found in the small intestine in dogs?
what are the clinical signs?, treatment and prognosis?
Adenocarcinoma - Locally invasive and progressive neoplasm, reducing the luminal diameter. Therefore, additional clinical signs include:
* Gastric – haematemesis (“coffee granules”)
* SI and Colonic – ribbon like faeces
At the time of diagnosis ~95% of gastric carcinoma has metastasised (local lymph nodes) and up to 58% of intestinal.
Treatment – surgical excision +/- draining lymph nodes.
Prognosis – Gastric (6 months), SI (4 – 18 months), Colorectal (2-4 years)
what two neoplasias of the dog that cause vomiting are similar in apparance, use immunohistochemistry to differentiate? what are the differences?
Leiomyosarcoma and Gastrointestinal Stromal Tumour (GIST)
Both are slow growing. Leiomyosarcoma primarily affects upper GI (stomach and SI) and GIST primarily lower GI (cecum and colon).
GIST expresses KIT receptors that increase proliferation – this can be reduced by tyrosine kinase inhibitors
Prognosis 2-3 years.
what neoplasia that causes vomiting in dogs is responsive to chemotherapy? what is the prognosis?
Lymphoma
A diffuse neoplasm meaning local excision is often not an option. However, responsive to chemotherapy depending on the degree of differentiation. Chemotherapy protocols include Wisconsin-Madison, Prednisolone +/- chlorambucil +/- cyclophosphamide.
Prognosis:
* Poorly differentiated, high-grade lymphoma – < 3 months
* Well differentiated, low grade, small cell – 1.5 to 2 years
* Large intestinal lymphoma – 5.5 – 6 years!
what two neoplasias affect the GUT of cats and cause vomiting? what is the prognosis for each?
Adenocarcinoma is less common in cats and prognosis is poorer compared to dogs.
Prognosis - Upper GI (5-15 months), Colonic (4-9 months)
Lymphoma – the most common GI neoplasm in cats.
As with dogs, diffuse, meaning chemotherapy is the main treatment.
Prognosis:
* Poorly differentiated, high-grade lymphoma – < 3 months
* Well differentiated, low grade, small cell – 2 to 3 years
what are the common causes, diagnosis, treatment and prognosis for gastrointestinal ulceration?
Common causes:
Steroids and NSAIDs, Neoplasia, Hepatic disease
Diagnosis – endoscopy. Ultrasound is less sensitive, but will detect free fluid/gas if perforation has occurred.
Treatment – evidence is poor for all of these.
Surgical - need to fix the perforation
* H2 receptor antagonist (e.g. Cimetidine) OR Proton pump inhibitor (e.g. omeprazole)
* Sucralfate
* Misoprostol – primarily consider in NSAID toxicity
Prognosis – completely depends on the underlying disease process.
what bacteria has been implicated in gastritis, ulcers and neoplsia?
Helicobacter
Curved, gram-negative, and motile
Very commonly isolated in normal and unwell dogs and cats – therefore their significance is unknown.
Diagnosis – endoscopic brush samples or biopsy of the stomach.
what toyes of chronic gastritis can dogs and cats get? how are these diagnosed?
Lymphocytic-plasmacytic gastritis and eosinophilic gastritis
These are histopath diagnoses (diagnosed with endoscopic biopsy) – i.e. it’s simply a description of the predominant inflammatory cell present.
Realistically – they both represent and abnormal, over-reaction of the local immune system. Dietary allergens (usually proteins) or antigens are probably the cause.
how is chronic gastritis treated in the dog and cat?
remove the allergen/antigen or suppress the immune response (or both)
Diet trial with hypoallergenic diet:
* Hydrolysed protein (commercially available, easy)
* Novel protein source (harder to source, probably more palatable)
Immunosuppression
* Prednisolone
* +/- azathioprine
* +/- cyclosporin
* +/- chlorambucil
