Download Practical Internal Medicine

Practical Internal Medicine
Don’t Throw Your Hands Up!
Keep It All Down
Managing the Vomiting Companion Animal
Wendy Blount, DVM
Nacogdoches, TX
Housekeeping
• Handouts other than PowerPoint slides are
already in your notebook
• You will get copies of the PowerPoint slides
after each section
•Course materials are also
downloadable at
http://wendyblount.com
•Click on “Presentation Notes”
•Click on the link for this seminar
Housekeeping
• Handouts other than PowerPoint slides are
already in your notebook
• You will get copies of the PowerPoint slides
after each section
•Course materials are also
downloadable at
http://wendyblount.com
•Click on “Presentation Notes”
•Click on the link for this seminar
Housekeeping
• Handouts other than PowerPoint slides are
already in your notebook
• You will get copies of the PowerPoint slides
after each section
•Course materials are also
downloadable at
http://wendyblount.com
•Click on “Presentation Notes”
•Click on the link for this seminar
Housekeeping
• Handouts other than PowerPoint slides are
already in your notebook
• You will get copies of the PowerPoint slides
after each section
•Course materials are also
downloadable at
http://wendyblount.com
•Click on “Presentation Notes”
•Click on the link for this seminar
Housekeeping
• Front Pocket – promotional literature
• Front - Table of Contents, Abbreviations
• Colored Tabs - writeable
– put each PowerPoint handout behind the designated
colored tab (bowls on the tables to recycle brads)
– Then you will find lab forms, diagnostic and treatment
handouts, client handouts, etc.
- Blue sheet subdividers
•Back Pocket – Evaluations and CE
certificate
Pretty Please complete the evaluation!!
Housekeeping
•
•
•
•
•
Red Tab – Vomiting
White Tab – Regurgitation
Blue Tab – Liver and Gall Bladder Disease
Orange Tab – Dry Lab Materials
Yellow Tab – Pancreatitis
•Green Tab – Feeding Tubes and TPN
•Pink Tab – Diarrhea
•Gold Tab – Acute Abdomen & Diagnostic
Surgery
Housekeeping
•
•
•
•
Breakfast, coffee and registration 7:30-8am
Morning Session 8am-12noon
Lunch break 12-12:30pm
Afternoon session 12:30-5pm
• We’ll break the last 10 minutes of
every hour
PLEASE PARTICIPATE!!
But take private conversations out in
the hall
Practical Medicine Philosophy
• As referral medicine becomes more
advanced, it by default becomes more
expensive
• Growing gap between general practice and
specialty practices
• These seminars help us fill those
gaps
• Everything we talk about this
weekend can be done in a rural
mixed animal practice
Practical Medicine Philosophy
• Some are already doing these things
– Feeding tubes, managing DKA, liver aspirates
• Some will be ready to begin
• Some will need some hand holding,
at least at first
– TexasVets – Yahoogroups
– Moderator Rosemary Lindsey
[email protected]
– Oncura - ultrasound
• Some will be happy to be better
referring vets
Agenda
Saturday – 8am-12noon, 12:30-5pm
• Vomiting
• Regurgitation
•
•
•
•
Lunch
Oncura Presentation
Liver & Gall Bladder Disease
Begin Pancreatitis
• (Sign CE Certificates & submit
Evaluations)
Agenda
Sunday – 8am-12noon, 12:30-5pm
• Pancreatitis
• Diarrhea
• Lunch
• Dry Labs
• Managing Feeding Tubes
• The Acute Abdomen
• Diagnostic Surgery
• CE Certificates & Evaluations
Why do Dogs & Cats Vomit?
•
A protective mechanism of
removing toxins from the body
• Endogenous and exogenous
• 43% gave GI disease
• 27% systemic illness
• 16% abdominal disease
• Neurologic 1-2%
• Miscellaneous 5-6%
Causes of Vomiting
•
Vomiting is the most common sign
of gastric disease
•
But not all vomiting dogs have
gastric disease
•
Not all dogs with gastric
disease vomit
Causes of Vomiting – GI Disease
Distal Esophagus
Stomach
Small Intestine
Large intestine
Pancreas
Liver & Biliary Tract
Causes of Vomiting – ExtraGI
Abdominal Dz – Acute or Chronic
Obstruction/Irritation from outside GI Tract
Foreign Substance in GI Lumen
Neurologic Disease
Systemic Disease
Toxicity
Environmental/Behavioral
Causes of Vomiting
That’s about a jillion causes
How do you find the cause in a particular patient?
Acute or Chronic?
2 weeks
Mild, Moderate or Severe?
1. Treat acute mild disease empirically
2. Diagnose and Treat Severe Dz ASAP
3. Proceed with diagnostics after discussion
with chronic & mod-severe acute vomiting.
Compartmentalize, then DAMNIT-V
Compartmentalization
Is vomiting from GI disease or secondary to something else?
Is the dog relatively well and vomiting,
or very sick and also vomiting?
Are there other symptoms not attributed to the GI tract?
Systemic Diagnostics for Systemic Disease
1 - Minimum database
2 – imaging & other tests indicated
3 - diagnostic surgery
GI diagnostics for GI Disease
GI Lab Tests, endoscopy
diagnostic surgery
DAMNIT- V
D – Degenerative
A – Anomalous
M – Metabolic
N – Neoplastic, Nutritional
I – Infectious, Inflammatory,
Immune Mediated, Idiopathic
T – Toxic, Traumatic
V - Vascular
Distal Esophageal Disease
chronic vomiting and regurgitation
DAMNIT-V
D – megaesophagus
A – hiatal hernia, megaesophagus
N – leiomyoma/leiomyosarcoma (GIST), SCC
I – GERD and distal esophagitis,
Spirocerca lupi
GERD – GastroEsophageal
Reflux Disease
Mandy
Sig: 14 year old SF dachshund
CC: not eating well, vomits daily,
getting worse gradually over 2
weeks
• has lost 2 pounds over 5 months
• Eating dirt for 2 months
• 3-4 episodes of vomiting and
diarrhea over the past year, one
with fever, all responded to
antibiotic therapy
Exam: does not allow deep
abdominal palpation, she’s a biter
Mandy
MDB:
•
•
•
CBC – neutrophilia 18,000/ul, PCV 25%
Panel – albumin 2.1 g/dl
lytes, UA, HW Test, fecal - NSAF
2nd round of tests:
•
•
Reticulocytes – 488,400/ul
• Highly regenerative
Fecal cytology
• No gross melena
• Many RBC seen on cytology
Mandy
Abdominal rads:
Mandy
Abdominal rads:
Mandy
Abdominal ultrasound:
Mandy
Abdominal ultrasound:
Mandy
Histopathology:
•
•
GIST – gastrointestinal stromal tumor
Comments
• generally slow-growing, and do not
metastasize.
• Neoplastic cells do not extend to the
specimen borders, and recurrence
will likely not be an issue for this dog.
Mandy
Thoracic rads
• NSAF on 3 view met check
• R lateral, L lateral, VD
Surgery – anastamosis and
resection:
•
•
Mass found at the duodenal flexure
NSAF in the remainder of the abdomen
Mandy
One year later: recurrence of all
symptoms, but sicker than before
Abdominal ultrasound:
Mandy
Abdominal ultrasound:
Mandy
Abdominal ultrasound:
Mandy
Lessons from Mandy:
• Sometimes histopathologic
diagnoses are incorrect
• Sometimes tumors do not behave
typically
• Make sure clients understand
both
Gastric Disease
DAMNIT-V
D - Degenerative
» gastric hypomotility
» gastric dysrhythmia
stomach motility seems normal when the stomach is empty,
but is incoordinated in response to solid food
» Dysautonomia
A – Anomalous
pyloric outflow obstruction (mucosal or muscular)
Gastric Disease
DAMNIT-V
N – Nutrition - acute
» Eating spoiled food
» Abrupt dietary change, when diet is uniform
» Gastric foreign body/material
» Eating too rapidly
Nutrition - chronic
» Dietary intolerance
Gluten in Irish Setters
» Food allergy
Gastric Disease
DAMNIT-V
N – Nutrition - acute
» Eating spoiled food
» Abrupt dietary change, when diet is uniform
» Gastric foreign body/material
» Eating too rapidly
Nutrition - chronic
» Dietary intolerance
Gluten in Irish Setters
» Food allergy
Gastric Disease
DAMNIT-V
N – Nutrition - acute
» Eating spoiled food
» Abrupt dietary change, when diet is uniform
» Gastric foreign body/material
» Eating too rapidly
Buster Maze Bowl
Nutrition
- chronic
» Dietary intolerance
Gluten in Irish Setters
» Food allergy
Gastric Disease
DAMNIT-V
N – Nutrition - acute
» Eating spoiled food
» Abrupt dietary change, when diet is uniform
» Gastric foreign body/material
» Eating too rapidly
Buster Maze Bowl
Nutrition
- chronic
» Dietary intolerance
Gluten in Irish Setters
» Food allergy
link
Gastric Disease
DAMNIT-V
N –Slo-Bowl
Nutrition
Kyjen “Hills”
- Kyjen
acute
“Coral” Slo-Bowl
» Eating spoiled food
» Abrupt dietary change, when diet is uniform
» Gastric foreign body/material
» Eating too rapidly
Nutrition - chronic
» Dietary intolerance
Gluten in Irish Setters
allergy
Kyjen
“Flower” Slo-Bowl
Kyjen “Drop” Slo-Bowl » Food
Gastric Disease
DAMNIT-V
N – Nutrition - acute
» Eating spoiled food
» Abrupt dietary change, when diet is uniform
» Gastric foreign body/material
» Eating too rapidly
Buster-Cubes
Nutrition
chronic
» Dietary intolerance
Gluten in Irish Setters
» Food allergy
Gastric Disease
DAMNIT-V
Green Bowl
N – Nutrition - acute
» Eating spoiled food
» Abrupt dietary change, when diet is uniform
» Gastric foreign body/material
» Eating too rapidly
Nutrition - chronic
» Dietary intolerance
Gluten in Irish Setters
» Food allergy
Gastric Disease
DAMNIT-V
N – Neoplasia – usually chronic
Lymphoma (LSA)
» most common gastric neoplasia in the cat
» 2nd most common gastric neoplasia in the dog
adenocarcinoma
» most common gastric neoplasia in the dog
» Most commonly in the pylorus
Leiomyoma – LMSA/GIST
» Most commonly in the cardia
» Usually asymptomatic unless pyloric outflow obstruction
or bleeding
Schirrhous adenocarcinoma, Fibroma/FSA
SCC, plasma cell tumor, MCT
Gastric Polyp – symptomatic if pyloric obstruction
Gastric Disease
DAMNIT-V
I – Infectious, Inflammatory – acute or chronic
• Bacterial - Helicobacter gastritis - chronic
• Fungal – phycomycosis, Histoplasma - chronic
• Parasitic
» Ascarids – puppies
» Physaloptera spp – acute
» Ollulanus spp
» Giardia spp – acute or chronic
» Neorickettsia spp (salmon poisoning) - acute
•
Chronic Gastritis
superficial, atrophic, hypertrophic
•
Gastric Ulcer – acute or chronic
Gastric Disease
DAMNIT-V
I – Idiopathic – chronic
•
•
Chronic gastric dilatation
» Anaerobic bacteria
» aerophagia
» Hypomotility
•
Acquired mucosal hypertrophy
•
Acquired muscularis hypertrophy
Duodenogastric reflux (bilious vomiting)
Immune Mediated – chronic
•
Inflammatory bowel disease
Gastric Disease
DAMNIT-V
T – Toxic, Traumatic
• Drugs – acute or chronic
Antibiotics, NSAIDs, immunosuppressives, cardiac glycosides,
anticholinergics, emetics
•
Toxins
» caustic substances – usually acute
pot pourri oil, cleaning supplies, fertilizers
petroleum distillates, organophosphates, toxic plants
» Heavy metals - chronic
lead, zinc
» Ethylene glycol - acute
•
Trauma – GDV, Diaphragmatic Hernia
usually acute, but can be chronic
Gastric Disease
Helicobacter Gastritis
• Associated with chronic gastritis, gastric and
duodenal ulcers, gastric carcinoma, gastric LSA
• Infection is often asymptomatic
• Treatment – triple therapy x 14 days
1. antibiotic 1 – metronidazole
2. Antibiotic 2 – amoxicillin or tetracycline
3. Antacids – bismuth or proton pump blocker
BTM – bismuth, tetracycline, metronidazole
OAM – omeprazole, amoxicillin, metronidazole
Baylor
2 year old spayed female GSD
Vomits bile daily, for 2 weeks
Exam - NSAF
1. CBC, profile, electrolytes, urinalysis, fecal, HW – NSAF
2. Imaging – Abdominal radiographs, practice does not
have abdominal ultrasound
Baylor
Baylor
Baylor
My recommendation was to take dog to surgery for
gastropexy and to explore spleen, or refer for abdominal
ultrasound.
Radiologist report says no significant abnormal findings.
Dog was treated empirically for vomiting.
Baylor presented for acute GDV at a local
clinic 2 weeks later, was euthanized. On
necropsy, the spleen was engorged and
large.
Lady
Middle aged spayed female GSD, presented for chronic
vomiting
1. CBC, profile, electrolytes, urinalysis, fecal, HW – NSAF
2. Abdominal radiographs showed an abdomen similar to
Baylors, except:
• No splenic mass
• Gas filled esophagus
•
3. Lady was taken to surgery, the chronic
GV reduced and tube gastropexy performed
--she was treated for esophagitis, fed
via tube for several weeks and recovered
Lesson from Baylor & Lady
•
•
•
•
Even the most talented consulting
specialists are not always correct
Consider all test results and input in the
context of the entire case and your clinical
experience
Sometimes the diagnosis is not on the
differential diagnosis list
Even the most dogmatically held tenets of
current veterinary medicine may ultimately
be exposed as falsehoods
• it’s not a character flaw to be wrong, but
it may be such a flaw to stubbornly
decline to acknowledge truth
• “Listen to Your Little Voice,” Susan
Hopper, DVM
Small Intestine
Bile in vomit indicates duodenogastric reflux
DDx similar to gastric vomiting
DAMNIT-V
N – Neoplasia – acute or chronic
•
Strangulation by a pedunculated tumor causing
volvulus (lipoma)
•
Intussusception of tumor
•
Obstruction by tumor or fungal mass
I – Infectious, Inflammatory
•
•
Antibiotic responsive diarrhea – chronic
Hemorrhagic gastroenteritis (HGE) - acute
Small Intestine
DAMNIT-V
I – Infectious – viral
•
•
Parvovirus, coronavirus
•
Rotavirus
Canine distemper virus
I – Idiopathic
•
Reverse intestinal peristalsis
T – Traumatic - acute
•
Mesenteric volvulus
•
Intussusception (palpate BID)
most commonly secondary to severe diarrhea
Large Intestine
Acute or chronic
DAMNIT-V
M – Metabolic - chronic
•
Hypothryoidism can predispose to megacolon
I – Inflammatory
•
•
•
HGE – acute or relapsing
Colitis – acute or chronic
IBS - irritable bowel syndrome
T– Traumatic
•
Constipation – acute or chronic
Pancreas
Acute Pancreatitis
Chronic Pancreatitis
Liver & Biliary Tract
Vomiting more common when there is cholestasis
Most icteric dogs vomit
Why do dogs with non-icteric liver disease vomit?
» Decreased gastric mucus, due to abnormal protein
synthesis.
» Decreased gastric epithelial cell renewal due to
abnormal protein synthesis.
» Decreased gastric blood flow, due to altered vasoactive
factors.
Liver & Biliary Tract
DAMNIT-V
•
M – Metabolic - chronic
Biliary sludging and/or mucocoele
•
Gall stone obstruction
N – Neoplasia - chronic
•
Hepatic carcinoma
•
Biliary carcinoma
•
LSA
•
Hepatoma
Liver & Biliary Tract
DAMNIT-V
•
I – Infectious – acute or chronic
Acute or chronic bacterial cholangiohepatitis
•
Viral hepatitis – chronic
•
Heterobilharzia spp – chronic
•
Fungal hepatitis
I – Inflammatory, Immune mediated – acute or chronic
•
Acute hepatic necrosis
•
Chronic active hepatitis
T - Trauma – acute
•
Biliary tract rupture
Abdominal Disease
Peritonitis (ascitic exudate) and resulting ileus
Abdominal pain
Impingement on the biliary and/or GI tracts by mass
DDx Peritonitis
•
Septic – perforated bowel or abscess, or localized
infection
•
Bile – ruptured biliary tract
•
Uroabdomen – ruptured urinary tract
•
chyloabdomen
•
Generalized enteritis
•
Pancreatitis
•
Viral - FIP
Abdominal Disease
DDx Abdominal pain – acute abdomen
•
•
Passing a kidney stone
•
pancreatitis
•
Biliary obstruction
•
GI obstruction
Rapidly growing mass in an encapsulated organ
(kidney, liver, spleen)
•
Abdominal abscess
•
Pyelonephritis
•
Splenic torsion
•
Cryptorchid testicular torsion
Abdominal Disease
DDx Impingement on the biliary and/or GI tracts by mass
Neoplasia
Cyst
•
Pancreatic cyst
•
Perirenal cyst
•
Choledochal cyst
•
Hepatic cyst
Abscess
Granuloma
Abdominal Disease
DDx Impingement on the biliary and/or GI tracts by mass
DDx Granuloma
I – Infectious - chronic
•
•
L-form bacteria
Ureaplasma, Mycoplasma spp
•
Mycobacterium spp
•
Bartonella spp
•
FIP
•
Many fungal infections
Abdominal Disease
DDx Impingement on the biliary and/or GI tracts by mass
DDx Granuloma
I – Inflammatory – necrosis or saponification of fat
•
•
Pancreatitis
•
Pansteatitis
Pancreatic adenocarcinoma
•
lymphangiectasia
I - rarely immune mediated
•
•
Idiopathic
Post rabies vaccine steatitis
Neurologic
Limbic Epilepsy
Seizure locus at the vomiting center
Responds to anticonvulsants (don’t use bromide)
Vestibular Disease
Neoplasia
Vomiting center (medulla) or CRTZ (brain)
Increased CSF pressure
Systemic Disease
Why do dogs with systemic disease vomit?
Chemical stimulation of the vomiting center &
chemoreceptor trigger zone.
Drugs that suppress this center
work best
Cerenia®
Systemic Disease
DAMNIT-V
M- Metabolic (ileus)
» Hypercalcemia
» Acute hypocalcemia
Eclampsia
» Hypokalemia
» hypomagnesemia
» hypothyroidism
» hypoadrenocorticism
» Hyperadrenocorticism
Systemic Disease
DAMNIT-V
M- Metabolic (toxic)
» Uremia
» Jaundice
» Sepsis
» Acidosis (lactate, ketones, necrosis, etc.)
Metabolic (idiopathic)
» Hyperthyroidism
Metabolic (shock)
Systemic Disease
DAMNIT-V
N – Neoplasia (paraneoplastic effects)
•
•
High gastrin levels
Gastrinoma
MCT
•
Hypercalcemia
Systemic inflammation
I – Infectious (unknown mechanism)
» Feline heartworm disease
» Systemic fungal infection
Systemic Disease
DAMNIT-V
T - Toxicity
» Hypercalcemia
Cholecalciferol rodenticide
Eczema cream (calcipotriol – Dovonex®) toxicity
» NSAIDs
» corticosteroids
» Acidosis – ethylene glycol
Systemic Disease
Why do dogs with renal failure vomit?
Direct toxicity to the gastric mucosa by renal toxins
Decreased renal metabolism of gastrin by the
kidneys, leading to elevated gastrin levels, and
increased HCl secretion in the stomach.
Drugs that protect the GI tract and stop
gastric acid secretion work best
sucralfate
Proton pump blockers >> H2 blockers
Systemic Disease
Why do dogs with NSAID toxicity vomit?
Direct toxicity to the gastric mucosa
Inhibition of gastroprotective prostaglandins
» Piroxicam, ibuprofen and naproxen undergo more
complete enterophepatic circulation, and thus have
prolonged half life in the dog and cat.
» COX2 selective are not as GI toxic as COX nonselective, but both can cause problems.
Prostaglandin analogs work best
misoprostol ( Cytotec® )
BID works as well as TID
Systemic Disease
Why do dogs with corticosteroid toxicity vomit?
Decreased mucosal cell growth and mucus production
Increased gastric acid secretion
High doses required for acute toxicity
Chronic toxicity when other risk factors present:
NSAIDs, hypotension, bile acid reflux, spinal cord
disease, liver disease, renal disease, Addison’s
disease, mast cell tumor degranulation, gastrinoma.
H2 blockers/proton pump blockers &
sucralfate work best
Systemic Disease
Can low dose aspirin be given with
immunosuppressive prednisone?
–
–
–
Graham and Lee, 2009 – IMHA dogs
–
study on healthy dogs
No GI ulcers with pred alone or pred + ultra low dose
aspirin (0.5 mg/kg SID)
– Combination does cause diarrhea
Nelger et al, 2000 & Rohrer, 1999
Corticosteroids did cause gastric erosions in
dogs with IVDD at high doses
No protection from omeprazole, H2 blocker or
misoprostyl
The Story of Bulldog – A Lesson in Forgiveness
Bull Dog
Sig: 10+ year old CM Boxer-Bulldog
CC: has been sick for about 10 days
•
•
•
•
•
•
Started with gagging
Progressed to vomiting 10-12x/day
Cerenia® reduced vomiting to 5-6x/day
Shivering last night
Not eating now, drinking OK
Bloodwork 2 weeks ago normal
Exam:
•
•
5-7% dehydrated
Abdomen difficult to palpate in this heavy
large dog – no discomfort noted
Bull Dog
MDB:
•
•
•
CBC – Neut 1900/mcL
Panel – BUN 28
lytes, UA, HW Test, fecal - NSAF
Supportive Treatment:
•
•
Bolus 10ml/lb LRS, then 2x maint
Ampicillin + enrofloxacin IV
2nd round of tests:
•
•
Abdominal radiographs
Ultrasound
Bull Dog
Abdominal rads:
R
Bull Dog
Abdominal rads:
Bull Dog
Abdominal Ultrasound:
• Multiple areas of distended, fluid
filled bowel in the jejunum/ileum
• Multiple focal areas of thickening
of the muscularis
• Cranial abdomen difficult to
interrogate, due to gas in the gut
• No foreign body found
Bull Dog
Barium Series: Why??
• Dog needed to be stabilized for
surgery
• No free fluid in the abdomen –
perforation unlikely
• Might as well get more info while
we wait
This clinic has no barium – only
gastrografin 
Bull Dog
Barium Series:
Bull Dog
Barium Series:
Bull Dog
Barium Series:
Bull Dog
Diagnostic Surgery:
•
•
•
Segmental ileus throughout the small
intestine
No foreign body found
Histopathology Dx – multifocal
muscularis hypertrophy
Bull Dog was euthanatized due to poor prognosis
and poor quality of life
Lessons from Bull Dog:
•
•
Expect to arrive at diagnoses that you didn’t know existed,
and may not understand
Some of us live and learn; Some of us just live.
Environmental/Behavioral
Motion sickness
Heat Stroke
Pain
Fear
Excitement
Dozens of Causes of Vomiting
Did that help us diagnose and treat our
vomiting patients?
Not a Lot!
Dozens of Causes of Vomiting
Did That Help?
Not a Lot!
Working Up the Vomiting Patient
Empirical Treatment first if indicated
Pattern Recognition
Step Wise Work-Up
Step 1 – Empirical Treatment
1. Cerenia PO SID x 1-4 days
2. Metronidazole 10-15 mg/kg PO BID x 7 days
250 mg tab – ¼ tab per 10 lbs
500 mg tab – ¼ tab per 20 lbs
Max dose 500mg
3. Deworm
pyrantel or Profender for cats
fenbendazole for dogs
Physaloptera spp.
Always deworm vomiting animals
Presentation:
acute or chronic onset of profuse vomiting
weight loss is usual
Sometimes anorectic, sometimes not
Diagnosis:
Almost never see the eggs on fecal
Deworming empirically prevents the
need for diagnosis by endoscopy
Physaloptera spp.
Physaloptera spp.
link
Clues in the Signalment
Deep chested breeds - GDV
Poodles – hypoadrenocorticism
Brachycephalic breeds - GERD,
hiatal hernia, pyloric mucosal
hypertrophy
GSD – antibiotic responsive
diarrhea
Clues in the History
If weight loss associated with
increased appetite - diabetes,
hyperthyroidism & IBD
Most common clinic sign of
gastric neoplasia – anorexia,
then weight loss, then vomiting
Step-Wise Plan for
Diagnosing Vomiting
1. Minimum Database
2. GI Diagnostics - Imaging, GI Lab,
ACTH Stim (26%)
– radiographs (15%) + contrast, US
(34%, FN 52%)
3.
4.
5.
6.
Flexible Endoscopy
Surgery with biopsies (85%)
Fluoroscopy
Empirical Tx for limbic epilepsy
& motility disorders
Step-Wise Plan for
Diagnosing Vomiting
1. Minimum Database
•
•
•
•
•
•
•
•
CBC, Profile (38%)
Electrolytes/blood gases
Urinalysis
Fecal flotation, direct smear (28%),
cytology
FeLV/FIV for all cats
T4/free T4 for cats > 5 years
HW Test for dogs
Coagulation testing if hematemesis
(Rose et al, 2010) – 200+ GI cases
Clues in the MDB
Polycythemia- HGE, neoplasia
•
Albumin normal with HGE, high with
dehydration, globulins high with neoplasia
Low albumin and globulin – protein
losing enteropathy, GI blood loss
•
HCT normal with PLE, low with GI blood
loss
Low albumin, normal globulin –
liver disease, protein losing
nephropathy, vasculitis
Clues in the MDB
Ethylene glycol toxicity pattern
•
•
•
Period of ataxia & vomiting at onset
Then ARF - Increased anion gap
Calcium oxalate crystals in the urine
Neoplasia pattern
•
•
•
•
•
Really sick with pretty boring bloodwork
Intermittent low grade fever
Hypercalcemia
Increased globulins
Increased white count
Clues in the MDB
Addison’s Disease pattern
•
•
•
•
•
•
•
Signs wax and wane
Hematemesis, hematochezia
Azotemia with moderately concentrated
urine (1.020’s)
Hypoalbuminemia
Hypercalcemia
High potassium and/or low sodium
Remember whipworms can cause
hyperkalemia and hyponatremia, as can
repeated abdominocentesis
TAMU GI Lab Tests
•
•
•
•
•
TLI/PLI – do you have significant
pancreatic disease?
B12/folate – do you have
significant intestinal disease?
Bile acids – do you have
significant liver disease?
Tritrichomonas PCR – chronic
diarrhea in cats
Alpha fecal proteinase – do you
have inflammatory bowel disease?
Gastrin
•
•
•
•
•
Made by gastric mucosa, pancreas
Eliminated by the kidneys
Increased with MCT, CRF, chronic proton
pump administration, gastrinoma
Stimulates the gastric mucosa to make HCl
TAMU GI Lab tests serum levels (form)
Causes problems:
•
•
•
•
GERD
Distal esophagitis and regurgitation
Ulcers in esophagus, stomach, duodenum
Chronic gastritis, duodenitis
McDuff
Sig: 16 year old CM Scottie
CC: not eating well for past 4-5
months, getting worse gradually
• has lost 5 pounds over 5 months
• Has vomited once weekly over
the past month, and has become
lethargic
Exam: thin body condition, QAR
McDuff
MDB:
•
•
•
CBC – NSAF
Panel – NSAF
lytes, UA, HW Test, fecal - NSAF
2nd round of tests:
•
•
•
Practice has a nice ultrasound, but does
not use it much for small animals
Abdominal radiographs
Barium study
McDuff
Abdominal rads:
McDuff
Abdominal rads:
McDuff
Mobile ultrasound the next week
confirmed gastric mass at the
pylorus
Owners elected euthanasia due to
slim possibility that surgery would
improve quality of life
Adenocarcinoma confirmed on
necropsy
When to do a barium study?
•
•
•
•
•
•
•
•
NOT just prior to an abdominal US
NOT just prior to a scope
NOT if perforation is suspected
If evidence of mural GI disease – to
check for obstruction
If you suspect a foreign body and can
not confirm on ultrasound
If you suspect a motility disorder
Abdominal contents are
malpositioned on x-rays
If you suspect a diaphragmatic hernia
Barium study for vomiting
Avoid drugs that inhibit GI motility
•
•
•
1.
2.
Opiates
beta agonists (bronchodilators)
Anticholinergics (atropine, aminopentamide)
Shoot scout films
Give barium
– 4-6 ml/lb small dogs and cats
– 2-4 ml/lb large dogs
3. Immediate for esophagram
4. Within 5 minutes for gastrogram
5. 30 minutes, and then every 1-2 hours until
barium is gone from stomach and enters
the colon
Barium study for vomiting
Thumb Rules for GI Transit Times
•
•
•
•
Barium should be in duodenum within 20 minutes
Stomach should be empty of liquid barium within 3-4
hours in the dog and 1 hour in the cat
Barium coated food can remain in the stomach for
12-15 hours in the dog and 4-5 hours in the cat
l make sure patient is fasted if you want to
evaluate transit time

l Never hesitate to extend barium series to
the next day if barium is not yet
completely in the colon
When to recommend endoscopy?
•
•
•
•
•
No evidence of systemic disease
outside the GI tract
Not suspecting lymphoma, which is
more often in the muscularis
Low albumin – poor surgical risk
Abnormal B12/folate indicate
significant intestinal disease
Owner wants low morbidity
procedure
Preparation for endoscopy
•
Withhold water the morning of scope
Upper GI:
• Withhold food and barium for 24 hours
• Withhold sucralfate for 48 hours
Lower GI:
• Withhold food and barium for 48 hours
• Biscodyl 5 mg PO 24 hours before
• Enemas 24, 12 and 1-2 hours before
• Or use GoLytely by stomach tube
When do you suspect a
Motility Disorder?
•
•
Minimum database and imaging NSAF
Prolonged GI transit on contrast study without
obstruction
Regurgitation without an identifiable cause
Other signs of peripheral neuropathy
•
•
–
–
–
•
•
Laryngeal paralysis
Spinal or cranial nerve deficits (LMN)
constipation
Other signs of dysautonomia
Presence of hypothyroidism, Cushing’s Disease,
Addison’s Disease, Myasthenia Gravis, spinal
cord disease, uremia, hypercalcemia,
hypocalcemia, etc.
Delayed Gastric Emptying
•
•
Criteria
–
Vomit undigested food > 8-12 hours after eating
–
Food still in the stomach 8-12 hours after eating
–
Liquid barium in stomach > 4 hours
–
US – gastric contractions <4-5/minute
DDx
–
outflow obstruction
•
Foreign body, infiltrative disease, stricture,
hypertrophy
–
Hypomotility
•
Pancreatitis
•
GI infiltrative disease
•
Opiates
•
Hypokalemia
•
Post surgery
•
parvovirus
Delayed Gastric Emptying
•
Diet
–
–
–
–
•
Liquid food
Low fat
Low protein
Low fiber
Prokinetics
–
–
–
Metoclopramide works only on the stomach
Cisapride may also work on the esophagus and colon,
at least somewhat
Erythromycin and ranitidine have prokinetic
characteristics
–
Erythromycin lower dose 0.25-0.5 mg/kg PO TID
–
Worsened by aminopentamide (Centrine®), opiates,
beta agonists
Effective in beagles but not Labradors
–
DDx Hematemesis
•
Blood swallowed
•
Blood coming from the erosive
disease in the stomach
•
Blood coming from erosive
disease in the duodenum and
refluxed into the stomach
•
Trauma
•
Coagulopathy
DDx Hematemesis
Blood swallowed and then vomited
and/or produces melena
– Trauma or coagulopathy can result in bleeding from any
of these areas
1. Respiratory tract
» Neoplasia
» Pulmonary thromboembolism (HW Dz)
2. Caudal nasopharynx (rostral nasal cavity bleeding
usually results in epistaxis)
» Neoplasia
» Fungal infection, dental disease
3. Oral cavity
» Dental disease
» Neoplasia
DDx Hematemesis
Causes of erosive gastritis – erosion more
superficial than an ulcer
»
»
»
»
»
»
»
»
Liver failure.
Kidney failure.
Hypoadrenocorticism.
Gastric neoplasia – see chronic vomiting.
MCT
Pancreatic neoplasia – gastrinoma.
Toxicity – NSAIDs > glucocorticoids, lead
Toxicity – caustic substances
» cleaning supplies
» pot pourri oil
DDx Hematemesis
Causes of erosive gastritis – erosion more
superficial than an ulcer
»
»
»
»
»
Trauma to the gut.
Shock – anaphylaxis, hypovolemia, septic, HGE.
Anesthesia (hypovolemia).
Spinal trauma.
Athletic exertion
DDx Hematemesis
Bleeding from the duodenum, refluxed
into the stomach.
–Ulcerative/erosive duodenal disease –
see differentials for gastric
ulcerative/erosive disease.
–Parasites – Coccidia, hookworms.
–See also Melena in the Diarrhea
Section.
DDx Hematemesis
Coagulopathy
1. Factor deficiency
» Liver failure
» Anti-vitamin K rodenticide toxicity
» congenital
2. Platelet problem
» Thrombocytopenia
» Platelet function defect
3. Blood vessel problem – vasculitis,
hypertension, hyperviscosity
4. Combination - DIC
DDx Hematemesis
Recurring Hematemisis and
Hematochezia are special
indications for ACTH Stim
Even if electrolytes are normal
Tx Hematemesis
•
Treat underlying cause
•
Continue sucralfate for 5-7 days after
hematemesis resolves
•
Continue proton pump or H2 blockers
for 10-14 days after hematemesis
resolves
•
Somatostatins inhibit HCl secretion
• octreotide
Nubbin Wayne
•
•
•
•
•
6 year old neutered male Boston Terrier
CC: lethargy, very attentive owners, UTD
Exam – pale pink mm, feces normal on rectal
CBC – PCV 21%, Hb 7 g/dl, RDW 20%
Panel/lytes – alb 2.2 g/dl, Ca 8.5 mg/dl,
Glob 1.3 g/dl, TP 3.5 g/dl
•
•
•
UA – NSAF (with sediment)
Fecal flot and direct – neg
Fecal cytology – RBC & proportional
WBC (peripheral blood)
Nubbin Wayne
Problem – anemia
• CBC – PCV 21%, Hb 7 g/dl, RDW 20%
• Panel/lytes – alb 2.2 g/dl, Glob 1.3 g/dl
• Fecal cytology – peripheral blood
DDx:
1. Blood loss -- suspect GI**
2. (Bone marrow disease)
3. (Chronic hemolysis)
Nubbin Wayne
Tier 2 tests:
• Reticulocyte count
• Check for autoagglutination
DDx EDTA tube agglutination:
• rouleaux
• autoagglutination
Nubbin Wayne
Tier 2 tests:
• Reticulocyte count
• Check for autoagglutination
DDx EDTA tube agglutination:
• rouleaux
• autoagglutination
Check for gross autoagglutination
• 1 drop saline + 1 drop blood on a
slide
• Tip on a white background
Nubbin Wayne
Tier 2 tests:
• Reticulocyte count
• Check for autoagglutination
DDx EDTA tube agglutination:
• rouleaux
• autoagglutination
Check for gross autoagglutination
• 1 drop saline + 1 drop blood on a
slide
• Tip on a white background
Nubbin Wayne
Tier 2 tests:
• Reticulocyte count
• Check for autoagglutination
DDx EDTA gross slide agglutination:
• rouleaux
• autoagglutination
Check for micro autoagglutination
• 5+ drops saline + 1 drop blood on a
slide, add cover slip
• Dilute until RBC are not touching
Nubbin Wayne
Tier 2 tests:
• Reticulocyte count
• Check for autoagglutination
DDx EDTA gross slide agglutination:
• rouleaux
• autoagglutination
Check for micro autoagglutination
• 5+ drops saline + 1 drop blood on a
Normal blood
slide, add cover slip
Nubbin Wayne
autoagglutination
• Dilute until RBC are not touching
• Poker chip analogy
Nubbin Wayne
Tier 2 tests:
• Reticulocyte count
• Check for autoagglutination
DDx EDTA gross slide agglutination:
• rouleaux
• autoagglutination
Check for micro autoagglutination
autoagglutination
• 5+ drops
saline + 1 drop blood on a
slide, add cover slip
• Dilute until RBC are not touching
• Look at stained feathered edge
Nubbin Wayne
Tier 2 tests:
•
•
•
•
Reticulocyte count - pending
Check for autoagglutination - negative
PT, PTT sent to local hospital – both high off scale
History? No know exposure to rodenticides
Tx:
•
•
•
•
Vitamin K3 2.5 mg/kg PO x 21d
Fenbendazole 50 mg/kg PO SID x 3d,
repeat in 2 weeks
Famotidine 10 mg PO SID
Sucralfate 0.5 g PO BID – 1 hr after other
meds and on empty stomach
Nubbin Wayne
Recheck 4 weeks later – lethargic again:
•
Reticulocyte count – 440,000/mcL
•
PCV 18%
•
PT, PTT sent to nearby vet clinic – both normal
•
History? No black tarry stools - normal
•
Fecal cytology – peripheral blood
DDx blood loss anemia:
•
GI blood loss
•
(third space blood loss, hemolysis)
Plan: recheck for autoagglutination - neg
•
Thoracic and abdominal rads – NSAF
•
Abdominal ultrasound – NSAF
•
Refer for endoscopy
Nubbin Wayne
endoscopy:
•
Bleeding ulcerative lesion in the ileum
•
Endoscopic biopsies – GIST, low grade
•
Clean borders on anastamosis and resection
•
Dx – leiomyosarcoma
Long term follow-up
•
No recurrence of neoplasia
•
Developed hyperadrenocorticism 6 years
later
•
Euthanized at the age of 14 for multiple
problems unrelated to neoplasia
Nubbin Wayne
Lessons from Nubbin Wayne:
•
Avoid using human labs for animal coags – calibration
makes results unreliable
•
Significant melena can be present but not grossly visible
•
Fecal cytology can help find it
•
Always confirm gross hemagglutination with microscopic
saline dilution >> 1:1
•
Pattern - Low PCV plus low alb & glob
•
look for GI blood loss
•
GI neoplasias can be present and bleed, but
not show up on x-rays or ultrasound
•
Erosive carcinomas are the most likely
offenders (Schirrhous ACA, SCC)
H2 Blockers
• Cimetidine (Tagamet®) 2.5-5 mg/lb PO IM IV
TID-QID.
– Inhibits hepatic microsomal enzymes.
– May increase half life of drugs that are metabolized in
the liver – theophylline, warfarin, phenobarbital.
– Can cause mental depression.
• Ranitidine (Zantac®) 1 mg/lb PO SQ IM IV BIDTID
– 5x as potent as cimetidine.
– Also a prokinetic, by inhibiting acetylcholinesterase.
– Inhibits hepatic microsomal enzymes as cimetidine, but
to a lesser extent.
H2 Blockers
• Famotidine (Pepcid®) 0.25-0.5 mg/lb PO IV SIDBID.
– Inhibits hepatic microsomal enzymes as cimetidine, but
to a lesser extent.
– 20x as potent as cimetidine.
• Nizatidine (Axid®) 1.25-2.5 mg/lb PO SID.
– 5x as potent as cimetidine.
– Also a prokinetic.
Proton Pump Blockers
– More effective than H2 blockers for mast cell
degranulation.
– Stronger suppressors of gastric acid secretion
than H2 blockers.
– Diminishes proteolytic effect of pepsin.
– Maximum effect at the 5th dose (may need to
use with H2 blockers for the first 3-4 days).
– Prolonged use (greater than 4 weeks) can
cause reversible gastric mucosal hypertrophy.
– Rebound hypersecretion of HCl can occur if
stopped abruptly (high gastrin levels due to
lack of feedback).
Proton Pump Blockers
– Omeprazole (Prilosec®) – 0.7-1 mg/kg PO SID
» 5 mg (1/2 capsule) PO SID, for dogs <11 lbs.
» 10 mg PO SID, for dogs 11-45 lbs.
» 20 mg PO SID, for dogs greater than 45 lbs.
– Lansoprazole (Prevacid®)
» 15 mg PO SID for small dogs
» 30 mg PO SID for large dogs.
– Esomeprazole (Nexium®)
» 0.7 mg/kg PO SID for dogs.
» Granules in capsule inactivated if sprinkled on
food.
– Pantoprazole (Protonix®) – 10-40 mg PO SID; 1
mg/kg IV SID.
– Rabeprazole (Aciphex®) – 5-20 mg PO SID.
Antiemetics
Central Antiemetics
• Phenothiazines - Act at both the CRTZ and the
vomiting center.
– Use only in well hydrated patients, without low blood
pressure, as they are hypotensives.
– Prochlorperazine (Compazine®) 0.25 mg/lb SQ IM TID
– Chlorpromazine (Thorazine®) 0.15-0.25 mg/lb SQ TID.
• Antihistamines - Act at the CRTZ
– Diphenhydramine (Benadryl®) 05-2 mg/lb PO IM or
SLOWLY IV.
– Dimenhydrinate (Dramamine®) 2-4 mg/lb PO TID.
– Meclizine (Antivert®) 12.5 mg PO SID for small dogs
and cats; 25 mg PO SID for medium to large dogs.
Antiemetics
Central Antiemetics
• Central Anticholinergics
– Scopolamine (Hyoscine®) 0.02 mg/lb SQ IM QID.
– Acts at vestibular center and CRTZ.
– Side effects ileus, dry mouth, sedation.
• Yohimbine (Yobine®)
– Acts at the CRTZ and the vomiting center.
– 0.15-0.25 mg/lb SQ IM BID.
Antiemetics
Peripheral Antiemetics
• Cisapride (Propulsid®)
– Antiemetic and prokinetic.
– Acts peripherally on the GI tissue – does not cross the
blood brain barrier, so no associated extrapyramidal
side effects.
– 0.05-0.25 mg/lb PO TID.
• Anticholinergics
– Aminopentamide (Centrine®) 0.1-0.4 mg IM SQ BIDTID.
– Side effect – ileus (undesirable when there is ileus or
motility disorder).
Antiemetics
Peripheral and Central Antiemetics***
• Metoclopramide (Reglan®) - Antidopaminergic
and antihistaminic, acts at the CRTZ
–
–
–
–
–
Antiemetic as well as prokinetic
0.2-0.4 mg/kg PO, SQ, IV TID-QID.
CRI – 0.5-1 mg/lb/day IV (works better as CRI)
Reduce dose by 50% in pets with renal failure
Side effects hyperactivity and constipation
(extrapyramidal signs) - more common in the cat
– For severe metoclopramide side effects, give Benadryl.
– Because serotonin receptors dominate in the feline
CRTZ rather than dopamine, metoclopramide may
not work as well as an antiemetic in cats, when
compared to dogs.
Antiemetics
Peripheral and Central Antiemetics***
Block vagal afferent neurons, act at the CRTZ & vomiting center
NK antagonists – inhibit substance P (analgesic)
– Maropitant (Cerenia®) 1 mg/kg SC SID, 2 mg/kg PO SID
for acute vomiting, no more than 5 days in a row (skip 1-2
days); daily up to 14 days in beagle study
– 8 mg/kg PO 2 hours prior to travel for motion sickness, for
no more than 2 days in a row (skip 3 days)
– Aprepitant – human drug
5HT antagonists
– Ondansetron (Zofran®) 0.5-1 mg/kg PO or 0.1-0.5 mg/kg
IV over 15 minutes SID-TID.
– Dolasetron (Anzemet®) 0.6 mg IV SID-BID.
– Side effects sedation and head shaking.
Antiemetics
Which are better? Sedlacek et al, 2008;
Conder et al, 2008
• Syrup of ipecac induced (peripheral) vomiting
– Cerenia and Ondansetron worked best
– both better than chlorpromazine, metoclopramide
• Apomorphine induced (CRTZ) vomiting
– Cerenia, metoclopramide, chlorpromazine best
– All 3 better than Ondansetron
• Presurgical
– All eliminated vomiting due to opiates
– Decreased anesthesia gas needed
Prokinetics
– Reduce gastroesophageal reflux
(increased LES tone).
– Help control vomiting by accelerating
gastric emptying.
– Improve coordination of antrum, pylorus
and duodenum.
– Increases propagation distance of
peristaltic waves.
– Contraindicated in cases with obstruction
(can precipitate perforation).
– Can usually wean prokinetics to the
lowest effective dose.
Cytoprotective Agents
• Bind to the ulcer/erosion to create a
physical protective barrier.
• Inactivate pepsin.
• Adsorb bile acids, which can be
inflammatory.
• Sucralfate (Carafate®) 0.5 g/15 lb PO
BID-QID – max 1 g
• Barium sulfate 2-6 ml/lb PO (same as for
upper GI series).
• Side effect constipation.
Mucosal Protective Agents
• Increase mucosal mucus and bicarbonate
production.
• Decrease mucosal acid production.
• Promote mucosal blood flow.
• Indicated for NSAID gastritis.
• Misoprostyl (Cytotec®) 2-5 ug/lb PO BIDTID.
• Side effects include:
– Abdominal cramping.
– Vomiting, diarrhea.
– Abortion.
Zoey
10 year old SF Aussie
CC: Has not been able to control her bladder
•
•
•
•
•
for about 6 weeks, occasionally vomits (once
a month); taking SMZ
She does not seem to be aware of urination –
it just dribbles out, wakes up in a puddle
Her bladder empties when owner lifts her
Had a bout of this 4 months ago, responded
to treatment with Proin®;
phenylpropanolamine no longer works
Occasionally feces drops out as she walks
Appetite and water intake are fine, energy is
fine; CBC/panel 6 weeks ago NSAF
Zoey
Exam:
• *Very* anxious dog – owner says this is
lifelong
• Pupils dilated and minimally responsive
PLR – owner say she squints in sunlight
• Took her outside to urinate – she urinates
a little while walking , but bladder is still
very full, and easily expressed
• Mild CP deficits rear limbs
• STT - >20mm/min OU
Zoey
CBC – NSAF
Panel/lytes – BUN 31
UA – USG 1.024, cocci on urine sediment
Abdominal US:
• Kidneys mildly hyperechoic with dilated
renal pelves
Urine C&S – pending
Tx: started marbofloxacin 50 mg PO SID x
21 days
Zoey
• Pilocarpine 0.1% 2 drops each eye
• Pupils 25% smaller in 15 minutes, with
bilateral rather normal PLR
• Pupils 50% smaller in 45 minutes
• Pupils pinpoint at 1 hour
• Atropine OU dilated the pupils again
Dx - Dysautonomia
Zoey
Tx – marbofloxacin 50mg PO SID pending
urine culture
• Taught owner to manually express bladder
• DES 1 mg 1-2x weekly
• Bethanechol 10 mg PO TID
Urine culture – methicillin resistant Staph
• Susceptible to amikacin, chloramphenicol,
doxycycline and marbofloxacin
• Resistant to 17 antibiotics
• Continued marbofloxacin for 6 weeks
• Urine culture within 1 week of stopping
marbofloxacin
Zoey
CBC, Panel/lytes - NSAF
Urine culture – another Staph
• Susceptible to everything but ampicillin,
enrofloxacin and SMZ
• Tx – Clavamox 250 mg PO BID x 4 weeks
• Urine culture negative after this round
Plan
• Recheck BUN, UA and urine culture in 30
days
• Continue manual expression of bladder,
Bethanechol, Proin, DES
• CBC q6months
Dysautonomia
First cases in Scottish horses in the 19 century
First reported in the cat in 1982, first dog in 1983
Degeneration of autonomic ganglia and failure of
autonomic function
History:
•
•
Vomiting, regurgitation, diarrhea
Anorexia weight loss, lethargy
•
Dyspnea, coughing
•
Photophobia
•
Dysphagia, dysphonia
•
dysuria
•
Onset over 1-2 weeks
Dysautonomia
Exam:
•
•
Decreased anal tone
•
Absent PLR, moderate mydriasis
•
Third eyelid prolapse
•
Dry mucous membranes and eyes
•
Crusty nose, nasal discharge
•
Dyspnea, pulmonary crackles, fever
•
Cachexia, weakness
Global LMN weakness and CP deficits on neuro exam
•
Large urinary bladder that is easy to express
•
Heart rate and blood pressure relatively low
Dysautonomia
Diagnosis:
•
Thoracic rads may show megaesophagus and/or
aspiration pneumonia
•
Ileus, bladder distension on abdominal imaging
•
Schirmer Tear Test less than 10mm OU
•
CBC, panel, CSF tap may be normal if no systemic
complications
Dysautonomia
Diagnosis:
Pilocarpine test
•
Place 1-2 drops 0.05% pilocarpine in one eye
•
Check PLR every 15 minutes for one hour
•
Normal dogs show minimal response
If dysautonomia, miosis due to denervation hypersensitivity
•
Can be false negatives
•
•
•
Chronic OP toxicity can produce similar results
Adding atropine will reverse the miosis in OP toxicity
but not dysautonomia
No tachycardia in response
to atropine injection
Dysautonomia
Treatment:
•
Bethanechol 1.25-5 mg PO BID or 0.05 mg/kg SC BID
•
SC seems to work better
•
Can help with urination and secretion
•
Can gradually increase to effect
Side effect – can increase vomiting and aspiration pneumonia
•
Pilocarpine eye drops
Can assist tear production and photophobia
Artificial tears OU PRN, Genteel, Soothe XP
Elevated feedings, prokinetics, permanent Gtube
Dysautonomia
Prognosis:
Grave
Mortality 70-90%
Those who survive have significant disability and progressively
debilitate
Dysautonomia
Pathology:
50% have megaesophagus
20% have aspiration pneumonia
Can diagnose with histopath on necropsy
Widespread degeneration of the autonomic nerves and ganglia
More than 50% are rural, outdoor dogs
Exposure to Clostridium toxins and/or
paraneoplastic disease
may play a role in pathogenesis
Handouts
•
.pdf of this PowerPoint
–
•
•
behind the red tab
Fluid Analysis Diagnostic Chart
TAMU GI Lab Submission Form
Handouts
•
Client Drug Handouts
–
–
–
–
–
–
–
–
–
–
–
Chlorpromazine
–
Cimetidine
–
Cisapride
–
Dimenhydrinate
–
Erythromycin
Amoxicillin
Oral antacids
Bethanechol
Bisacodyl
Bismuth subsalicylate
–
–
–
–
–
Famotidine
Fenbendazole
Maropitant
Metoclopramide
Metronidazole
Omeprazole
Praziquantel
Pyrantel pamoate
Ranitidine
Sucralfate
Handouts
•
Client Handouts
–
–
–
–
–
–
Diaphragmatic hernia
Endoscopy
Gastric Dilitation & Volvulus
Hemorrhagic gastroenteritis
Vomiting in Cats
Vomiting in Dogs
Acknowledgements
DeNovo RC, Chapter 5, “Diseases of the Stomach,” in
Todd R Tams Small Animal Gastroenterology, 2nd
Edition.
Adam Honeckman, DACVIM
Mobile Veterinary Diagnostics, Orlando FL
Margie Scherck, DABVP
VIN Consultant