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BVM3 Alimentary > Vomiting and Regurgitation Diagnostic Approach > Flashcards

Vomiting and Regurgitation Diagnostic Approach Flashcards

1
Q

What is the basic diagnostic approach for vomiting?

A

Define the problem –> Define the system –> Define the location –> Define the lesion

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2
Q

What kind of activity is vomiting?

A

Vomiting is a coordinated activity

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3
Q

What are the 4 main components of the emetic reflex? Which of these components are usually targeted by treatments?

A
  1. Visceral Receptors - targeted by treatments
  2. Vagal and sympathetic afferent neurons
  3. Chemoreceptor Trigger Zone (CRTZ)
  4. Vomiting Center within reticular formation of the medulla oblongata
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4
Q

Vomiting is almost always preceded by ________

A

Nausea

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5
Q

How does the CRTZ trigger vomiting?

A

No BBB in this zone which means anything can get in to trigger vomiting response

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6
Q

Where are visceral receptors located?

A

In the gut

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7
Q

What is the function of vagal and sympathetic afferent neurons?

A

Take messages for vomiting

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8
Q

What are the 3 Stages of Vomiting? Describes the steps which happen at each stage

A
  1. Nausea
    - Reduced gastric tone
    - Duodenal and proximal jejunal tone is increased
    - Duodenal contents refluxed into the stomach
    - Depression, hypersalivation, repeated swallowing
  2. Retching
    - Vomiting without bringing anything up
  3. Vomiting
    - Glottis closed, soft palate pressed up against nasopharynx (protects against aspiration)
    - Abdominal muscles and diaphragm contract
    - Will not see diaphragm contracting, but will see abdomen contracting
    - Cardia opens, pylorus contracts (stomach)
    - Reverse peristalsis
    - Cardiac rhythm disturbances, changes in colonic motility
    - Some animals defecate at the time of vomiting (pressure)
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9
Q

How does regurgitation differ from vomiting?

A

Regurgitation is a passive process while vomiting is an active process

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10
Q

What can often induce/exacerbate or encourage regurgitation?

A
  • Alterations in food consistency
  • Exercise
  • Facilitated by gravity when the head and neck are held down and extended
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11
Q

What are the receptors in the vomiting center and which 2 drugs target this site?

A

a2, NK1, 5HT1a
NK1 antagonists, Phenothiazines

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12
Q

What are the receptors in the CRTZ and which 4 drugs target this site?

A

D2, M1, H1/H2, 5HT3, NK1
NK1 antagonists, Phenothiazines, Antihistamines, Metclopramide

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13
Q

What are the peripheral receptors and which 3 drugs target these receptors?

A

M2, D2, NK1, 5HT3, Motilin
NK1 antagonists, Metclopramide, Anticholinergics

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14
Q

What is the receptor in the vestibular system and which 4 drugs target this site?

A

M1
Anticholinergics, NK1 antagonists, Phenothiazines, Antihistamines

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15
Q

What can affect the vomiting center and what are these sites responsible for?

A

CRTS, Toxins, Vestibular system (motion sickness, inner ear infection), Nucleus tractus solitarius (integration), Peripheral receptors (gut, abdominal organs), Higher CNS (pain, fear smell)

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16
Q

Which 2 systems responsible for vomiting can also communicate with each other?

A

CRTZ and vestibular system

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17
Q

Where does the physical/observable action of vomiting vs. regurgitation originate from?

A

Vomiting - comes from the stomach
Regurgitation - comes from the shoulders

18
Q

What comes up from vomiting vs. regurgitation?

A

Vomiting - bile (or reflux) + stomach contents (no saliva)
Regurgitation - Undigested food + saliva

19
Q

Can vomiting/regurgitation be ruled out based on pH analysis of contents brought up?

A

No

20
Q

Can either vomiting or regurgitation be treated symptomatically?

A

Vomiting can usually be treated symptomatically, but regurgitation cannot.

21
Q

What is regurgitation usually a sign of if its a persistent condition?

A

Usually a sign of a “bad” disease

22
Q

How does investigation of vomiting vs. regurgitation differ?

A

Vomiting - investigation using biochemistry, hematology, UA, abdominal imaging, endoscopy, ex-lap
Regurgitation - investigate using imaging of esophagus or endoscopy. Doing hematology, biochem, and ex-lap is a waste of owner’s money and can be dangerous for patient.

23
Q

What is the best thing to do if you find a foreign body during endoscopy in a patient experiencing regurgitation?

A

Best to push FB into the stomach to allow passage/surgical retrieval rather than retrieve it/pull it out from esophagus or let it sit in esophagus for longer.

24
Q

What is primary vs secondary GI disease?

A

Primary GI disease - structural disease, stomach to colon
- Define as either surgical or medical
Secondary GI disease - functional disease
Accessory digestive organ (pancreas)
- Electrolyte imbalance (Na+, K+, Ca2+)
- Endogenous toxins (kidney, liver, ketoacidosis, infection)
- Exogenous toxins
- Primary CNS

25
Q

How does investigation of primary vs secondary GI disease differ?

A

Primary GI disease - IMAGING most useful (rads, U/S)
- Labs might give info about clinical signs, but rarely about the cause of vomiting
Secondary GI disease - Hematology, UA, imaging, ex-lap, endoscopy

26
Q

Is vomiting always related to eating?
What is the exception?

A

Vomiting does often relate in time to eating, but the only exception is pancreatitis

27
Q

Does vomiting not related to eating rule out primary GI disease? Why?

A

No - Vomiting may be delayed for some hours in animals with non-inflammatory gastric disorders

28
Q

Give some examples of situations when an animal might vomiting despite not eating?

A

Foreign body
Secretory disorders of the bowel

29
Q

How does vomiting usually occur in relation to eating in lower bowel disorders?

A

In lower bowel disorders vomiting usually occurs at variable times after eating

30
Q

When should primary GI disease be strongly suspected?

A
  • An abnormality is palpable in the gut (FB, intussusception)
  • Vomiting is associated with significant diarrhea
  • Patient is clinically and historically normal in all other respects
  • The onset of vomiting significantly preceded any development of signs of malaise, depression and/or anorexia
  • Important to check if vomiting started earlier than presentation at the vet office
  • Vomiting is consistently related in time to eating
31
Q

How do you define the location in primary GI disease?

A

Anywhere from stomach to the colon
Use barium meal, barium enema, endoscopy, proctoscopy, laparotomy

32
Q

How do you define the lesion in primary GI disease?

A

Split into diseases of the stomach vs diseases of the intestine

33
Q

What are the most common primary GI causes of vomiting?

A

Gastritis - spoiled food, dietary indiscretion, food intolerance
Viral infection - Parvo, Corona, Rotavirus
Foreign body
GI neoplasm

34
Q

When should secondary GI disease be strongly suspected?

A
  • Patients usually metabolically ill (Exceptions: Early pancreatitis, Hyperthyroid cats)
  • Vomiting occurred subsequent to the onset of other signs of malaise, inappetence and/or depression
  • Other clinical signs present (jaundice, PU/PD)
35
Q

What should you do if you can’t tell if its primary vs secondary GI disease?

A

Define the location - define the organ involved –> Define the lesion

36
Q

What are some secondary GI causes of vomiting?

A

Pancreatitis
Liver or Renal Disease
Endocrine Disease (Ex. Diabetic ketoacidosis, Addison’s, Hypercalcemia)

37
Q

What changes about the order of logical approach in regurgitation vs vomiting?

A

In regurgitation defining the location and lesion comes before defining the system that is responsible –> This will lead us to finding out that the problem is in the esophagus
Most causes of regurgitation are primary structural problems with the esophagus and defining the system responsible only relates to the condition of megaesophagus

38
Q

Describe congenital vs acquired megaesophagus?

A

Congenital
Acquired
- Primary (idiopathic) vs Secondary (systemic causes)
- Myasthenia gravis, Hypoadrenocorticism (reversible)

39
Q

What are some lesions that can cause esophageal disorders (defining the lesion) and regurgitation

A

Anatomic
- cricopharyngeal disease, hiatal hernia,
diverticulum
Megaesophagus
- congenital vs acquired
External compression
- persistent R aortic arch ie. vascular ring
anomaly (congenital)
- Mediastinal lymphoma
- Thyroid tumors
Internal obstruction
- FB
- Stricture
Esophagitis
- Trauma
- Reflux of gastric acid
- Irritation
Intramural lesions
- Neoplasms, Abscesses, Granulomas
- Parasites (ex. Spiroserca lupi in endemic
areas)

40
Q

When is symptomatic therapy appropriate for a vomiting patient?

A

Appropriate when primary GI disease has transient cause (dietary indiscretion, toxin)
or Mild pancreatitis

41
Q

When is symptomatic therapy NOT appropraite for a vomiting/regurgitating patient?

A

Signs of secondary GI disease
Patient is dehydrated, painful or depressed

42
Q

When do you need to go further and assess the metabolic effects of vomiting on a patient?

A

No response to symptomatic therapy
Vomiting is present and severe
Other clinical signs present suggesting secondary GI disease (PU/PD, Jaundice, Anemia)

BVM3 Alimentary (24 decks)

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