Vomiting & Diarrhea Flashcards
List four “inputs” to the vomiting center
- abdominal viscera
- CRTZ
- vestibular apparatus
- cerebral cortex
Top extra-GI causes of V/D in dogs
- pancreatitis
- liver failure
- kidney failure
- hypoadrenocorticism
Top extra-GI causes of vomiting and diarrhea in cats
- pancreatitis
- liver failure
- kidney failure
- hypoadrenocorticism
- hyperthyroid (V/D)
- heartworm disease (V)
Most important primary GI rule outs
- GI obstruction (foreign body)
- parvovirus if puppy
Most important extra-GI rule outs
acute pancreatitis or other organ system failure
Large bowel vs. small bowel diarrhea
Small:
- increased appetite-unless sytemic illness
- weight loss
- large volume but normal frequency
Large:
- normal appetite
- no weight loss
- increased frequency
- tenesmus
- frank blood/mucus
Components/steps to history in V/D cases
- Make sure to correctly identify problem
- If diarrhea, determine small or large bowel
- Determine if the problem is acute or chronic
- Establish how severe the V/D is
- Assess whether primary or extra-GI disease seems most likely
- Diet and enviroment
- diet change or dietary indiscretion
- foreign body/toxin access
- potential for GI pathogens
- vaccination/deworming Hx
- current meds
Ddx for panhypoproteinemia
How will you differentiate?
- PLE
- Blood loss
Differentiate with PCV; if patient not anemic, blood loss likely not the issue!
Ddx for low albumin and normal globulin
- PLN
- liver failure
- vasculitis
What should you do if you r/o extra-GI causes and determine the problem is small bowel diarrhea?
rule out EPI with a TLI
Fiber supplementation is often helpful to treat what?
chronic large-bowel diarrhea
Abdominal radiographs are really good for?
ruling in obstruction
What are some breeds predisposed to IBD or lymphangiectasia?
- yorkies
- soft-coated wheaten terriers
- lyndehunds
- basenjis
What are some possible causes of PLE?
- moderate to severe IBD or lymphangiectasia
- neoplastic infiltrate of GI tract (e.g. lymphoma)
- fungal or heavy parasitic infection (e.g. pythium, histoplasmosis, ancylostomiasis, strongyloides)
PLE-complications
- thoracic and/or abdominal effusion (secondary to low albumin)
- thromboembolism secondary to loss of antithrombin III
- ionized hypocalcemia (due to deficiency/malabsorption of vitamin D)
Components of a minimum database for infectious V/D
- FeLV/FIV test-cats
- wet mounts
- centrifugation flotation
- Giardia SNAP test
- treat with fenbendazole
What should you include in your minimum database for infectious V/D if large bowel diarrhea
- culture or PCR(preferred) for T. foetus - cats
- rectal scraping cytology
An infectious agent PCR panel might be really helpful when the patient is showing what signs?
- systemic illness
- fever
- leukocytosis
- bloody diarrhea
What treatment considerations are there for lymphocytic/plasmacytic IBD?
- fenbendazole/metronidazole
- elimination diet/treatment response trials
- parenteral B12 if low
-
steroids +/- cytotoxic agent
- cyclosporine or azathioprine (dog)
- chlorambucil (cat)
What additional diagnostics would you consider if you found neutrophilic IBD?
- fenbendazole/metronidazole
- elimination/diet/treatment response trials
- parenteral B12 if low
- antibiotics
Treatment considerations if you found eosinophilic IBD?
- fenbendazole/praziquantal
- elimination diet/treatment response trials
- parenteral B12 if low
- steroids +/- cytotoxic agent
Treatment considerations if you found granulomatous IBD
- fenbendazole/metronidazole
- elimination diet/treatment resopnse trials
- parenteral B12 if low
- antibiotics with intracellular activity (e.g. Baytril)
Treatment considerations if you find lymphangiectasia
- Fenbendazole/metronidazole
- parenteral B12 if low
- ultra low-fat diet
- steroids +/- cytotoxic agent
If an animal has polyphagia + weight loss + diarrhea, what does your differential list consist of?
- not feeding enough
-
malassimilation
- EPI
- small intestinal malabsorption
- hyperthyroidism
- diabetes mellitus
Etiology of EPI
- autoimmune lymphocytic (dogs)
- chronic pancreatitis (cats, dogs)
What breed is predisposed to EPI?
GSD
What are the predominant clinical signs of EPI?
weight loss +/- small bowel diarrhea
Top PRIMARY GI disease differentials for ACUTE V/D
- dietary indiscretion/hypersensitivity
- acute gastritis or gastroenteritis (HGE, parvo, parasitic, bacterial, protozoal)
- drug-induced
- obstruction (FB, GDV, intussusception)
- GI ulcers
Anti-emetics that work at the vomiting center
- Chlorpromazine (alpha antagonist)
- Maropitant (NK1 antagonist)
- Ondansetron-cats (5-HT3 antagonist)
What anti-emetics act on the abdominal viscera?
- maropitant
- ondansetron-dogs
What anti-emetics are effective at the CRTZ?
- Maropitant
- Chlorpromazine
- Metaclopramide-dogs
HGE etiology
- intestinal anaphylaxis; possible role of C. perfringens?
What finding increases suspicion for HGE?
high PCV with normal TP
Treatment for HGE
aggressive fluid therapy + abx with anaerobe activity (ampicillin, metronidazole)
Ddx for acute vomiting-primary GI dz
Dietary factors/indiscretion
- overeating/gluttony
- abrasive material
- toxins(caustic agents, plants, mycotoxins,bacterial)
- food sensitivity (intolerance or allergy
Inflammatory/infectious
- Gastritis (dietary indiscretion, food sensitivity, foreign body)
- Enteritis/enterocolitis
- HGE
- parvo, others
- Parasitic (ascarids, hookworms, roundworms)
- Gastrduodenal ulcers
Obstructive/ischemic
- gastric or intestinal FB
- GDV
- intestinal intussusception
Ddx for acute vomiting-extra-alimentary disease
- acute pancreatitis
- hepatobiliary (acute hepatopathy, cholangitis, biliary obstruction)
- genitourinary (acute renal failure, nephroliths, prostatitis, pyometra)
- peritonitis
- septicemia
- endocrine (hypoadrenocorticism, DKA, hyperthyroidism)
- neuro (vestibular dz)
- motion sickness
- drugs (chemo, abx)
Ddx for chronic vomiting-primary GI disease
Inflammatory
- chronic gastritis
- Bilious vomiting syndrome
- idiopathic chronic gastritis
- food sensitivity
- neoplasia (adenocarcinoma, LSA)
- drugs (NSAIDs, steroids)
- chronic enteritis/enterocolitis
- IBD
- neoplasia(adnenocarcinoma, LSA)
- gastroduodenal ulcers
Partial or recurrent obstruction
- gastric FB
- GI neoplasia
- chronic intestinal intussusception
- recurrent constipation
Ddx for chronic vomiting-extra alimentary tract disease
- chronic pancreatitis
- genitourinary (chronic renal failure, chronic prostatitis)
- hepatobiliary (chronic hepatopathy, cholecystitis, biliary obstruction)
- endocrine disease (hypoadrenocorticism, hyperthyroidism)
Ddx for hemamesis/melena
Coagulopathy
- thrombocytopenia
GI erosions/ulcers
- idiopathic chronic gastritis
- IBD
- parasites (hookworms)
- GI neoplasia (gastric, duodenal)
- gastric hyperacidity disorders (MCT)
- drugs (NSAIDs, steroids)
- miscellaneous
- acute pancreatitis
- hypoadrenocorticism
- renal failure
- liver failure
- ischemic (DIC, shock, heat stress, thromboemboli)
- neuro (spinal cord trauma in conjunction with corticosteroid use)
Always perform what in cats 7 years and older with chronic V/D?
T4 test
What are some other reasons besides pancreatitis that amylase/lipase could be increased?
- dehydration
- renal failure
- gastroenteritis
- corticosteroids-may increase serum lipase
Usefulness of PLI
- detects lipase of pancreatic origin only
- most sensitive test of dx canine and feline pancreatitis
The presence of what other findings along with V/D might indicate performing basal cortisol to screen for hypoadrenocorticism in dogs?
- low Na/K ratio
- hypercalcemia
- eosinophilia
- lack stress leukogram
Characteristics of a hypochloremic metabolic alkalosis
- high pH or TCO2
- high bicarb
- positive base excess
- low chloride
When should you consider upper GI endoscopy?
- animals with chronic vomiting, diarrhea, or weight loss where initial laborartory and imaging studies failed to ID cause
- acute or chronic vomiting where there is potentially retrievable foreign body
- persistent upper GI bleeding
Main drawbacks to endoscopy
- does not evaluate entire GI tract (i.e. can miss lesions in listal duodenum, jejunum, and ileum)
- endoscopic biopsies are only mucosa +/- submucosa
Characteristics of a good elimination diet
- highly digestible
- gluten and lactose free
- protein restricted
- single source CHO and protein
- novel protein source or hydrolyzed protein
When to consider exploratory laparotomy
- ALWAYS when GI obstruction or septic peritonitis is suspected
- when lab tests and imaging studies fail to reveal a cause for chronic vomiting or diarrhea; esp. if endoscopy unavailable
- focal mural masses/thickenings are found (resections may be needed)
- imaging studies show that abnormalities are most prominent in the distal SI
- need to examine abdominal organs besides the gut (e.g. liver, pancreas)
Name the four mechanisms of diarrhea
- osmotic
- secretory
- permeability
- motility
Name two breeds particularly predisposed to parvovirus
- Rottweiler
- Doberman pinscher
Name two breeds clasically predisposed to PLE
- soft-coated wheaten terriers
- yorkshire terriers
Miniature schnauzers predisposed to what causes of diarrhea
- HGE
- hyperlipidemia
- pancreatitis
German shepherds are predisposed to what causes of diarrhea or dyschezia
- EPI
- antibiotic-responsive diarrhea
- IBD
- perianal fistulae
Many small-breed dogs are predisposed to what cause of diarrhea?
HGE
Ddx for acute diarrhea-primary GI disease
Dietary factors/indiscretion
- overeating
- sudden diet change
- toxins/food poisoning
- food sensitivity
Inflammatory/infectious (enteritis, enterocolitis, and/or colitis)
- HGE
- parvo, other viruses
- parasites (ascarids, hookworms, whipworms)
- sharp/traumatic foreign material
Partial obstruction/ischemia
- intussusception
Ddx for acute diarrhea - extra alimentary
- acute severe pancreatitis (segmental colitis)
- hypoadrenocorticism (more often chronic)
- sepsis, toxemias
- drugs (commonly abx)
Ddx for chronic small bowel diarrhea-primary GI disease
Dietary
- food sensitivity (intolerance/allergy)
Idiopathic chronic enteropathies
- IBD
- food-responsive diarrea
- antibiotic responsive diarrhea
- lymphangiectasia
Infiltrative/infectious
- intestinal neoplasia (LSA, adenocarcinoma, mastocytosis)
- parasites (ascarids, hookworms, giardia)
Partial obstructions
- chronic intussusception
- intestinal neoplasia (LSA, adneocarcinoma, leiomyoma/myosarcoma)
Ddx for chronic small bowel diarrhea-extra alimentary
- EPI
- hepatobiliary (liver failure)
- genitourinary (renal failure)
- endocrine
- hypoadrenocorticism-dogs
- hyperthyroidism-cats
Do extra-GI causes of diarrhea usually result in large or small bowel diarrhea?
small
Ddx for chronic large bowel diarrhea-primary GI dz
Dietary
- fiber responsive colitis
- food sensitivity (intolerance/allergy)
Idiopathic chronic enteropthies
- IBD
- FRD
- ARD
Infiltrative/infectious
- colonic/rectal neoplasia (adenocarcinoma, LSA)
- parastic (whipworm, tritrichomonas)
Obstructive/ischemic
- chronic intussusception (ileocolic, cecocolic)
Secondary to chronic small bowel diarrhea
What might be an extra-alimentary cause of chronic large bowel diarrhea?
renal failure (“uremic colitis)
Ddx for PLE
- IBD
- intestinal neoplasia-esp. LSA
- lymphangiectasia
Ddx for weight loss despite good appetite
Malabsorption/maldigestion
- chronic SI dz
- EPI
Endocrinopathies (excessive catabolism)
- DM
- hyperadrenocorticism-dogs
- hyperthyroidism-cats
PLN
Ddx for constipation/dyschezia
Dietary
- ingested indigestible material (bones, cat litter, plant)
Painful/inflammatory
- colitis/proctitis
- prostatitis
- anal sac disease (sacculitis, adenocarcinoma)
- perianal fistulae
- spinal disease/back pain
- pelvic/hip/hind limb pain
Obstructive
- perineal hernia
- prostatomegaly (prostatitis, adenocarcinoma)
Motility disorder
- idiopathic megacolon
- lumbosacral spinal cord disease
Miscellaneous
- Dehydration-chronic renal failure
Low cobalamin is seen with what diseases?
EPI, ileal disease
Low folate is seen with what disease
proximal small intestinal disease
Cause of increased folate
common with high dietary intake +/- bacterial overgrowth
Why is fecal alpha-1 protease inhibitor useful?
It is a protein with a similar molecular weight to albumin, but is NOT degraded in the feces. It can be assayed to detect or confirm the presence of PLE. It can detect subclinical PLE in susceptible populations (predisposed breeds) before the become hypoproteinemic, and is useful to monitor response to therapy.
What antibiotics are commonly used in antibiotic response trials?
tylosin, metronidazole
Histiocytic ulcerative colitis (“Boxer colitis”) is treated with what?
enrofloxacin
If diarrhea continues despite appropriate therapy for EPI, what is a good next step?
antibiotic response trial
Why are survey films always indicated in constipation cases?
evaluate pelvic structures, lumbosacral spine, prostate, and look for abdominal masses and foreign material
Why do liver and kidney dis
Famotidine MOA
H2 blocker
Omeprazole MOA
PPI
Maropitant MOA
NK1 antagonist
chlorpromazine MOA
alpha-adrenergic receptors
Metaclopramide MOA
dopamine receptors
Ondansetron MOA
Serotonin receptor antagonist
