Vomiting + Regurgitation Flashcards by laura knight

Give 3 forms of obstructional oesophageal disease

Mural (stricture)
Luminal (foreign bodies)
Extralumenal (mass)

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Give 4 anatomical oesophageal diseases

Vascular ring anomaly
Cricopharyngeal disease
Hiatal hernia
Diverticulum

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Give 3 causes of oesophagitis

Trauma, reflux (anaesthesia), irritation

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Give 3 motility disorders of the oesophagus

Megaeosophagus
Neuropathy
Myopathy

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What are the 3 most common causes of oesophageal disease?

Oesophagitis
Oesophageal foreign body
Mega-oesophagus

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Outline the clinical signs associated with regurgitation

Hypersalivation
Odynophagia
Dysphagia (pharyngeal problem more likely)
Nasal discharge
Coughing (due to 2ry aspiration pneumonia)

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Outline the differences between vomiting and regurgitation

Vomiting: abdominal effort, nausea, digested food, no swallowing pain (May be alkaline or acidic substance) MOST COMMON
Regurgitation: passive, no nausea, undigested food, possibly painful (usually alkaline)

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Which questions may distinguish vomiting from regurgitation?

abdominal effort/wretching?
digested food being brought up?
when in relation to eating?
swallowing difficulties?
pain on eating?
do they look nauseous?

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What does physical exam usually reveal for oesophageal disease?

Nothing - usually normal
Lung auscultation may reveal aspiration pnumonia
Underlying/concurent disease
Body condition may indicate how chronic the disease is

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What are the most common investigations to carry out? What else may be carried out?

Diagnostic imaging -plain/contrast radiographs
Heamotology and biochemistry
Endoscopy

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What are the most common differential diagnoses for megaoesophagus?

Idiopathic (dogs)
Myasthenia gravis (generalised or focal)
Thymoma
Hypoadrenocorticism

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What is the prognosis of megaoesophagus? What is the treatment?

Poor
Death usually results from repeated aspiration pnumonia
Treatment aimed at minimising occourence of pnumonia eg. elevate food and water
Hold vertical after feeding
Experiment with food consistency - liquid go down better but may be aspriated, solids harder to swallow but less likely to be aspirated
Manage pnumonia

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Why is aspiration pnumonia associated with megaoesophagus?

Regurgitation not associated with reflex closure of the larynx (vomiting IS)

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What are the causes of oesophagitis?

chemical injury: corrosive agents, medications (doxycycline esp in cats if gets stuck)
gastro-oesophageal reflux: GA, hiatal hernia, persistent vomiting, feeding tubes if positioned incorrectly
Oesophageal foreign bodies

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How can oesophagitis be treated?

Dietary - small meals high protein low fat food to minimise reflux ± gastric feeding tube
Sucralfate liquid - “chemical bandage”
Inhibitors of gastric acid secretion - H2 blockers, proton pump inhibitors

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What is a possible serious complication of oesophagitis?

Strictures due to serious irritation if FB remains for >24hours

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Where do oesophageal FBs usually lodge?

Lodge at thoracic inlet, heart base, hiatus

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What is required to assess and treat oesophageal FBs? What is a potential complication?

Endoscopy - retrieval/push to stomach

Potential for mucosal damage/perforation

What is vomiting?

Foreful expulsion of GI contents
Symptom NOT disease
Primitive toxin elimination mechanism

What may stimulate vomiting?

Brainstem vomiting centre responsible, inputs from:
Cortex
Vagal and sympathetic afferents from gastirits
Brainstem chemoreceptor trigger zone (CRTZ)

Once vomiting has been diagnosed, what is the next step?

Define/refine the problem

chronic/acute
primary GI/ secondary GI

List 4 causes of ACUTE primary GI vomiting

Dietary - indiscretion/intolerance/hypersensitivity
Infection - Parasites/parvovirus
Obstruction - Neoplasia/FB/gastric hypertrophy
Motility disorders/gastic volvulus

List 2 causes of CHRONIC primary GI vomiting

Inflammatory disease - Gastritis/IBD/ulceration

Neoplasia

List 6 causes of secondary (metabolic) causes of vomiting. How would you distinguish the cause as secondary?

Ureamia (vUSG, PUPD associated with chronic renal failure)
Addison’s disease (adrenocoritcal insufficiency)
Hepatic disease
Pancreatitits
Toxin ingestion
Drugs (iatrogenic)
> often NOT the only clinical sign

How can you rule out secondary (metabolic) causes of vomiting?

Heamaology/biochemistry | Urinalysis

How can diagnositc imaging be used when working up a vomiting animal?

Radiographs for obstruction | Ultrasound for other organ involvement

Give 6 causes of stomach ulcers. Which is most common?

Neoplasia - lymphoma, carcinoma, leiomyoma/sarcoma Inflammation - Gastritis Iatrogenic - NSAIDS *Most common* Systemic - Hypoadrenocorticism, liver dysfunction, uraemia, mast cell tumour->hyperhistamineamia, gastrinoma->hypergastrinaemia. Hypotension - shock, DIC, sepsis Other/idiopathic - stress, spinal surgery

What is the treatment of acute and chronic vomiting?

Acute: fasting and treat symptoms Chronic: find underlying cause!

Give 3 classes of drug used to treat vomiting

Anti-histamines Anti-cholinergics Proton-pump inhibitors eg. Omeprazole

What is the mechanism of action of sucralfate? What is it good for?

- Aluminium hydroxide and sucrose octasulfate, dissociates in acid and becomes sticky polymer which adheres to proteinaceous exudate found at ulcer sites. - Provides a protective barrier and stimulates HCO3-, mucus and PG secretion. - Good for oesophageal as well as gastirc ulceration

What is another name for Sucralfate?

Antepsin, sulcrate, pepsigard

What is the dosing of Sucralfate?

20kg: 1mg/dog q6-8hrs

What are some names of H2 receptor antagonists?

Cimetidine Rinitidine (zantac) Famotidine

What is the mechanism of action of cimetidine/ranitidine/famotidine? What are the disadvantages of them?

H2 receptor antagonist - inhibition of gastric acid and some gastric PROKINETIC activity Disadvantages: No evidence of its efficacy in cats/dogs Expensive BID/TID

What is the mechanism of action of omeprazole?

Proton pump inhibitor - binds H+/K+ > long T1/2 -> SID

What is omeprazole indicated for?

Gastric hyperacidity GI ulcers Zollinger-Wllison syndrome (gastrinoma) > good evidence for this in vet use

When is anti-emetic therapy indicated?

Vomiting is debilitating - pain - marked fluid/electrolyte loss Remember vomiting can be debilitating

Which MODERATE antiemetic is licensed for vet use?

Metoclopramide - PABA derivative with central and GI effects - antagonises CRTZ and peripheral cholinergic effect - Upper GI prokinetic > moderate activity (not strongest)

How can metoclopramide be given?

Tablets, suspension, injection | - 0.2-0.5mg/kg im, sc, po q6-12hrs or as CRI

Which is the most potent anti-emetic? Why is it rarely used? When would it be indicated?

``` Ondansetron (zofran) - 5HT antagonist - CRTZ action only >expensive - indicated for chemotherapy patients and pancreatitis ```

Which antiemetic works on the final step before the vomiting centre?

Maropitant - NK1 R ant - Laos has peripheral effects

Why should care be taken when using maropitant?

Very potent. May mask underlying disease.

Which species is maropitant licensed in? What are the dose rates for these species?

Dogs (1mg/kg sc q24hrs or 2mg/kg po q 24hrs) | Cats (0.5-1mg/kg po, sc q 24hrs)