Oesophageal diseases and Vomiting

Question 1

What are the categories of differentials for regurgitation?

Answer 1

Anatomic
Obstruction
Oesophagitis
Motility Disorders

Question 2

Which are the 3 most common DDx for regurgitation?

Answer 2

Oesophagitis
Foreign Body
Megaoesophagus

Question 3

What are the clinical signs of regurgitation?

Answer 3

Hypersalivation
Odynophagia
Anorexia - uncommon
Dysphagia
Nasal dischage
Coughing (aspiration pneumonia)

Question 4

How can regurgitation be distinguished from vomiting?

Answer 4

Vomiting:

• abdominal effort
• prodromal nausea
• digested food
• no swallowing pain

What is the relationship to eating? i.e. regurgitation is usually within 30 mins of eating

Question 5

What other elements of history/examination can aid with diagnosis of regurgitation?

Answer 5

Oesophageal palpation
Lung ausculation - aspiration pneumonia
Concurrent disease?
BCS?

Question 6

What is the next step after regurgitation has been defined as the problem?

Answer 6

Diagnostic Imaging - survey then possibly contrast radiographs
Endoscope if the above don’t help

Question 7

What are the common causes of mega oesophagus?

Answer 7

Idiopathic megaoesophagus - management
Myasthenia gravis
Thymoma
Hypoadrenocorticism

Question 8

Why is aspiration pneumonia likely with regurgitation?

Answer 8

Unlike vomiting, regurgitation is not associated with reflex closure of the larynx. Aspiration pneumonia is very serious and can be life threatening.

Question 9

What are the things that can cause oesophagitis?

Answer 9

Chemical injury (including medication)
Gastrooesophageal reflux - GA, hiatal hernia, persistent vomiting, poorly positioned feeding tubes
Oesophageal FBs

Question 10

How can oesophagitis be treated?

Answer 10

PPIs
Protectant e.g. sucralfate
Dietary changes - high protein - low fat food.

Question 11

What is a serious complication of oesophagitis?

Answer 11

Strictures - narrowing/tightening of the oesophagus

Question 12

Outline procedures for dealing with an oesophageal FB.

Answer 12

Endoscopic removal of push back to stomach.
Consider referral as this is an emergency and if not dealt with within 24hrs then it could lead to stricture of the oesophagus.

Question 13

Describe the physiology of vomiting.

Answer 13

The chemoreceptor trigger zone in the brainstem can be affected by drugs, toxins, ureamia, infections etc. The vomiting centre in the brainstem can also be affected by the cortex, vagal and sympathetic afferent (e.g. with gastritis).

Question 14

How can the problem of vomiting be refined?

Answer 14

Is it acute or chronic (chronic = >2-3 weeks)

Is the lesion primary (GI) or secondary (extra-GI)

Question 15

What are the different primary causes of vomiting.

Answer 15

Dietary - indiscreation, intolerance, hypersensitivity
Infections - parasites, parvovirus
Inflammatory disease - gastritis, IBD, ulceration
Neoplasia
Obstruction - neoplasia, FB, gastric hypertrophy
Motility disorders/gastric volvulus

Question 16

Which are the most common primary causes of vomiting?

Answer 16

Dietary indiscretion
Infection
Inflammatory disease
Neoplasia 
FBs

Question 17

Which of the primary causes of vomiting are most likely when the vomiting is chronic?

Answer 17

Inflammatory disease
Neoplasia

n.b. the others mentioned in the other questions are more likely to be acute.

Question 18

What are the secondary causes of vomiting?

Answer 18

Uraemia - may see PU/PD
Hypoadrenocorticism
Hepatic disease
Pancreatitis
Toxin ingestion (acute vomiting)
Drugs

Question 19

What is the diagnostic approach with vomiting?

Answer 19

Bloodwork and urinanalysis if not clear whether primary or secondary as this will indicate a metabolic problem.
Diagnostic imaging if, after testing, a primary GI problem is suspected.
Endoscopy/biopsies if nothing else suspected

Question 20

What is the course of treatment for acute vomiting usually?

What if this doesn’t work?

Answer 20

Fasting and symptomatic treatment

If the vomiting becomes chronic then an underlying cause needs to be elicited

Question 21

What types of drug can be used to treat vomiting (when excess acid production? Briefly say why these can be used.

Answer 21

Anti-histamines and anticholinergics - H2 and M2 receptors on parietal cells. Histamine is produced by mast cells and Acetylcholine is from the vagus.

PPIs - these are the most potent. They prevent H+ secretion from the parietal cells

Question 22

What is sucralfate?

Answer 22

It is a drug that forms a protective barrier in the stomach and oesophagus. It is formed from aluminium hydroxide and sucrose octasulphate. The latter reacts with HCl to form a sticky substance that binds to proteinaceous exudate often found at ulcer sites.

It also stimulates production of HCO3-, mucus and prostaglandin. Indicated for ulceration

Question 23

What anti histamine drugs are there?

Answer 23

Cimetidine, Ranitidine, Famotidine (CRF)

Question 24

Are the anti-histamines used for vomiting?

Answer 24

Yes frequently, however, there is no proven efficacy!

Question 25

When is anti-emitic therapy indicated?

Answer 25

If the vomiting is debilitating and there is no obstruction

If there is marked fluid/electrolyte loss.

Question 26

What is metaclopromide? Is it licenced?

Answer 26

PABA derivative. It antagonises D2 and 5-HT3 receptors centrally and cholinergic receptors peripherally. It has moderate efficacy and is licenced for veterinary use.

Question 27

What is ondasteron and its efficacy?

Answer 27

It is a 5-HT3 antagonist and is very good for chemotherapy induced vomiting as it affects the chemoreceptor trigger zone.

Question 28

Why is maropitant so potent?

Answer 28

It is a neurokin-1 receptor antagonist, which is the last step before vomiting. Have to be careful as it may mask underlying disease and is useful in any kind of vomiting unless obstructive.