Vomiting + Regurgitation Flashcards
Give 3 forms of obstructional oesophageal disease
Mural (stricture)
Luminal (foreign bodies)
Extralumenal (mass)
Give 4 anatomical oesophageal diseases
Vascular ring anomaly
Cricopharyngeal disease
Hiatal hernia
Diverticulum
Give 3 causes of oesophagitis
Trauma, reflux (anaesthesia), irritation
Give 3 motility disorders of the oesophagus
Megaeosophagus
Neuropathy
Myopathy
What are the 3 most common causes of oesophageal disease?
Oesophagitis
Oesophageal foreign body
Mega-oesophagus
Outline the clinical signs associated with regurgitation
Hypersalivation
Odynophagia
Dysphagia (pharyngeal problem more likely)
Nasal discharge
Coughing (due to 2ry aspiration pneumonia)
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)
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?
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
What are the most common investigations to carry out? What else may be carried out?
Diagnostic imaging -plain/contrast radiographs
Heamotology and biochemistry
Endoscopy
What are the most common differential diagnoses for megaoesophagus?
Idiopathic (dogs)
Myasthenia gravis (generalised or focal)
Thymoma
Hypoadrenocorticism
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
Why is aspiration pnumonia associated with megaoesophagus?
Regurgitation not associated with reflex closure of the larynx (vomiting IS)
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
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
What is a possible serious complication of oesophagitis?
Strictures due to serious irritation if FB remains for >24hours
Where do oesophageal FBs usually lodge?
Lodge at thoracic inlet, heart base, hiatus
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)
