Exam 1 Flashcards
(107 cards)
1
Q
Lec 1 Clinical Manifestations of GI Disorders
A
2
Q
- Recognize and describe the common c/s of GI Disease in the C/F patient
Dysfunction in what nerve and innervated structures usually result in regurgitation?
A
C/S
- Dysphagia: difficulty in eating
-Oral pain (feline stomatitis)
-Masses
-Foreign objects
-Trauma
-Neuromuscular dysfunction: Masticatory muscle myositis, rabies - Neurogenic Dysphagia
-Rabies
-Prehensile, pharyngeal or cricopharyngeal
-Prehensile: inability to pick up food or food dropping from mouth: CN V, VII, IX, XII deficits
Pharyngeal and cricopharyngeal dysfunction usually results in regurgitation
- Halitosis
-Abnormal bacterial growth, especially pathogenic oral bacteria (anaerobes, gram negatives)
-Tissue necrosis
Calculus/periodontal disease
-Oral/esophageal retention of food - Drooling (Ptyalism, Pseudoptyalism)
-Ptyalism: excessive salivation
-Usually associated with nausea
-Toxins, sour.bitter tastes
-Pseudoptyalism: saliva leaks from mouth as patient is too painful or unable to swallow - Vomiting
-Expulsion of material from stomach or intestines
-Active process with abdominal motion and prodromal (period between initial symptoms and full development of disease) - Regurgitation
-Expulsion of food, water, saliva from mouth, pharynx or esophagus
-Passive process
-Different from vomiting or expectoration
3
Q
- Differentiate between vomiting and regurgitation in the C/F patient based on history and c/s
A
- Vomiting
-Motion sickness
-Ingestion of emetogenic substances
-GI obstruction
-GI inflammation
-Triggering of CRTZ drugs, toxins, disease outside of GI tract - Regurgitation
-If also dysphagic, consider oral, pharyngeal or cricopharyngeal disease
-If not dysphagic, esophageal dysfunction is most likely
a. Esophageal stricture (cats and doxycycline)
b. Esophagitis
c. Gastroesophageal reflux (GERD)
d. Megaesophagus - Expectoration
-Expulsion of material from respiratory tract
-Can be confused with regurgitation or vomiting
-Generally associated with cooughing when it occurs
-Coughing in dogs often stimulates a gag reflex and possible vomiting
Hematemesis
-Expulsion of digested blood or fresh blood
-GI ulcers, Neoplasia, Coagulopathies, NSAIDs
Acute diarrhea
-Most commonly diet, parasites, infectious diseases
Chronic diarrhea
-Parasites, infiltrative disease, neoplasia, immune-mediated disease
-Determine if SI or LI
4
Q
- Differentiate between small bowel and large bowel diarrheas in the C/F patient based on history and clinical presentation
A
- Chronic small intestine diarrhea
-Maldigestion
-Malabsorption: non-protein losing or protein losing - Chronic large intestine diarrhea
-Evaluate rectal and colonic mucosa first (neoplasia, fungal disease)
-Therapeutic trials
-Further diagnostics
5
Q
- Differentiate between small bowel and large bowel diarrheas in the C/F patient based on history and clinical presentation
Hematochezia & Melena
A
- Hematochezia
-Fresh blood in/on feces
-Associated with large bowel disease - Melena
-Digested blood that is coal black (not dark brown or green)
-Associated with small bowel disease or upper GI disease (Gastro duodenum ulcers)
6
Q
- Differentiate between small bowel and large bowel diarrheas in the C/F patient based on history and clinical presentation
Tenesmus & Dyschezia
Constipation & Obstipation
A
- Tenesmus
-Ineffectual or painful straining at urination or defecation
-Must differentiate between urination and defecation - Dyschezia
-Painful or difficult elimination of feces from the rectum - Constipation
-Infrequent and difficult evacuation of feces
-Drugs, behavioral, dietary, obstruction, weakness, etc.
-Megacolon: neurological dysfunction - Obstipation
-Intractable constipation
-Example: megacolon in cats - Fecal incontinence
-Neuromuscular disease: cauda equina syndrome, lumbrosacral stenosis
-Evaluate anal reflex, as part of a complete neurological exam
-Severe proctitis (inflammation of the rectum) can cause urge incontinence - Weight loss
Small intestine only
-Food related: insufficient calories, poor quality
-Anorexia/dysphagia
-Regurgitation/vomiting
-Maldigestion
-Malabsorption
-Cancer
-Excessive calorie utilization
-Loss of nutrients
-Neuromuscular disease - Anorexia, hyporexia
-Common finding secondary to CNS disease or other disease process
-Inflammatory disease anywhere in the body
-Anorexia: complete loss of appetite
-Hyporexia: partial food intake - Abdominal pain
-Differentiate from other pain ( disk disease)
-Pacing, assuming positions to alleviate pain, looking/licking at abdomen
-PE: grunt, tense, vocalizes or tries to bite - Acute Abdominal pain
-Abdominal disorders causing shock, sepsis and/or severe pain
-Generally emergent conditions
-Ex: GIT obstruction or leakage
-Vascular compromise (torsion)
-Inflammation
-Neoplasia
-Sepsis - Abdominal enlargement
-Tissue: organomegaly, pregnancy, neoplasia
-Fluid: ascites, pyometra, cysts (ultrasound better)
-Gas: contained GDV or free (ruptured)
-Fat: obesity or lipoma
-Abdominal muscle weakness: ex Cushing’s disease
-Feces
7
Q
- When presented with the history and C/S of a C/F patient, develop an appropriate and ranked differential diagnoses list for GI diseases (ch 26 SAIM textbook)
Which glucocorticoid is most commonly associated with hematemesis?
A
-Dexmethasone
8
Q
Lecture 2
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Diagnostic test for alimentary tract
9
Q
- Compare and contrast the following diagnostic imaging modalities used in evaluating GI disease in the C/F patient: radiography, contrast-enhanced radiography, and ultrasound
A
Contraindications for Barium
-Suspect GIT perforation
-Intractable vomiting or aspiration
-Fractious patient in need of heavy sedation
10
Q
A
11
Q
Ultrasonography
A
-Complements radiography
-Very operator dependent
-Assesses the thickness, echodensity and homogeneity of organs
-5-MHz probe most useful, clip hair
12
Q
- Describe and select the appropriate common diagnostic laboratory tests used in evaluating gastrointestinal disease in a clinical patient: minimum database (CBC, Chem, UA), fecal parasite testing, bacterial fecal culture, ELISA/IFA/PCR fecal analyses, fecal cytology and special tests for GI disease (serum gastrin, Helicobacter testing, fecal alpha-1 protease inhibitor)
Which dx test would you use to test for GI protein loss?
Which dx test would use to evaluate bacterial overgrowth, small intestinal disease?
A
Dx Testing
- PE: thorough oral exam, under the tongue, may require sedation
-Identify individual organs on abdominal palpation: Dog: SI, LI, bladder, Cats: also both kidneys - Dog: Rectal exam/palpation (mucosa, anal sphincter, anal sacs, pelvic canal, pelvic urethra and colonic contents)
- Minimum database
-CBC: important if suspect anemia, infection, neutropenia, thrombocytopenia
-Serum biochemistry: liver enzymes, kidney enzymes, electrolytes, glucose, proteins (esp albumin)
-Urinalysis - Fecal parasite testing
-Centrifugation method preferred
-GI disease weight loss = fecal!
-Repeated fecal needed for intermittent shedding parasites: whipworm, Giardia.
-Reference lab testing for roundworm, hookworm, whipworm fecal ELISA, fecal antigen testing IDEXX
-Motile trophozoites of Giardia or Tritrichomonas might be seen on direct, saline wet mount smears - Bacterial Fecal Culture
-Seldom needed
-Clostridium spp., salmonella spp., Campylobacter jejuni, Yersinia enterocolitica, Enterotoxic E. coli, Tritrichomonas fetus (cats) - ELISA/IFA/PCR fecal analyses
-ELISA parvovirus (Ag): very specific, best after 24-48 hours of C/S when virus is actually shedding. Very specific
-ELISA SNAP Giardia Test (Ag): sensitive; good negative predictive value
-PCR panels
-IFA for Giardia/Cryptosporidium - Fecal Cytology
-May identify inflammatory cells or etiologic agents
-Leukocytes in feces indicates transmural inflammation (not just superficial mucosal inflammation)
Presence of spore-forming bacteria is not sensitive or specific for clostridial colitis - Special Tests
-Serum gastrin: if gastrinoma is suspected
-Helicobacter testing: testing for urease activity
-Fecal alpha-1 protease inhibitor: used to evaluate for gastrointestinal protein loss
-Serum TLI (Trypsin-like immunoreactivity) for EPI - exocrine pancreatic insufficiency
-Serum cPLI or fPLI for pancreatitis
-Vitamin B12 (cobalamin) and folate
13
Q
- Describe the indications, patient preparation, and techniques in performing endoscopy and colonoscopy in the C/F patient, including the recognition of key anatomical features.
What are the pros/cons?
Can you obtain full thickness biopsies?
A
- Endoscopy/Colonoscopy
-Useful if radiography and ultrasound findings are non-diagnostic
-Rigid endoscope: colon, esophagus, foreign body removal
-Flexible endoscope: oral, esophageal, stomach, duodenum, colon
-Pros: rapid evaluation of Upper and lower GIT morphologic changes; can easily obtain mucosal biopsies non-surgical removal of foreign bodies; relatively non-invasive
-Cons: can not reach the mid-GIT; can not obtain full-thickness biopsies; insensitive for evaluating GIT function, must prep before procedure. - Laparotomy Goals
-Biopsies: obtain full thickness bipsies and tissue from outside the GIT
-Treatment: definitive treatment of a variety of abdominal disease - e.g., acute abdomen, masses, foreign bodies. Incision from xiphoid to pubis
14
Q
- Compare and contrast common GI biopsy techniques in the C/F patient and given the physical exam findings and clinical characteristics of an affected C/F patient, select the appropriate biopsy technique
A
Signalment:
-1 yo
-Female
-Golden Doodle
-Intact
Hx
-Vomiting for past 2 days, tenderness on abdominal palpation
-Still eats
-TPR normal, MM: pink, CRT 2 sec
-Got into garbage
Problems list
1. Vomiting Ddx: foreign body obstruction, liver disease, toxic, GI tract perforation, bacterial/fungal infection.
2. Abdominal tenderness Ddx: foreign body obstruction, liver disease, GDV, toxic, GI tract perforation, bacterial/fungal/viral infection.
Dx
-Radiographs
-Minimum database (CBC, urinalysis, Chem)
-Ultrasound
-cPLI
-fecal flotation
15
Q
A
16
Q
Lecture 3
A
General Principles for GI Disorders
17
Q
- When presented with the history, C/S and PE findings of a C/F patient with GI disease, develop an appropriate fluid therapy plan to include fluid choice (crystalloids, colloids, hypertonic solutions), administration route (IV- parenteral, oral, SC, Intraosseous, intraperitoneum)
A
General Therapeutics
- Fluid therapy
-Address dehydration, shock and electrolyte imbalance
-Must determine acid-base status, electrolyte abnormalities
Traditionally 0.9% Saline pending blood work +/- 20 mEq KCl/L AAHA guidelines **
-Volume benefits the patient much more than the exact composition of the fluid
-Isotonic fluids hardly ever wrong
Type
- Blood products for oncotic support: fresh plasma, frozen plasma, whole blood
- Canine-specific Albumin, Human specific albumin (generally not recommended)
- Colloids: Hydroxyethyl HES starches: pull in fluids from interstitial into intravascular space. Colloids can overhydrate the patient
-Hypoalbuminemia: common in GIT disease.
-Liver, kidney issues can impact albumin levels
Route
- Enteral: best route for GIT if patient can not tolerate oral fluids
- SC: only for mild dehydration or maintenance
- Parenteral: hypovolemic/dehydrated or patient can not tolerate enteral fluids.
- Intraosseous: very young, small with challenging IV access (trochanteric fossa, wing of the ilium, humerus)
Rate
-Dictated by rate and severity of fluid loss
-Replace like with like (Acute-rapid, chronic-slowly)
-Electrolyte imbalances within </= 24 hours corrected best
18
Q
Questions to ask to determine fluid rate
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19
Q
Dehydration Deficit formula
A
Body Wt (kg) *[(%dehydration/100)] = deficit in litters
Ex: 35 kg * 0.07 = 2.45 L or 2,450 mls
20
Q
Maintenance fluid needs calculation
A
Maintenance 45-60mls/kg/24hrs or
(BW kg) ^0.75 * 132 (dogs) or 80 (cats)
Ex: 35kg*60mls/24hrs = 2,100 mls/day
21
Q
Ongoing losses
A
Ex: 2 cups of vomiting/diarrhea in the last hour
-Estimate in mls/hr
-Monitor patient
-Determine if adjustments need to be made
1 cup = ~240mls
240mls*2hr = 480 mls losses which need to be replaced
22
Q
Put it all together and determine fluid rate
A
-7% dehydration = 2,450 mls deficit
-V/D last 2 hrs = 480 mls losses
-Maintenance/day = 2,100 mls
(2,450 + 2100 + 480) = 5,030 mls/24 hrs
Bolus: initially (10-20 mls/kg) = 35*10 mls = 350 mls/hr or mls/15-30 minutes
Then: (5,030 mls - 350 mls) = 4,680 mls/24 hr = 195 mls/hr
-Make adjustments based on your patient’s response to fluids, check weight.
-Give additional fluid boluses, synthetic colloids or hypertonic saline as needed
-Cats overhydrate easily
**Don’t forget to add KCl to fluids at some point, but no more than 0.5 mmol/kg/hr due to bradycardia, arrhythmias risk
23
Q
- When presented with…. develop an appropriate dietary management plan to include calculation of caloric requirements, route of administration (oral, enteral, parenteral), and diet selection
A
Dietary Management
-Particularly in acute symptomatic non-specific GIT disease
-Bland, easily digestible diets
-Homemade boiled chicken, boiled rice, boiled potatoes, low fat cottage cheese
- Hypoallergenic
-Sole source protein/antigen diets
-Hydrolyzed diets (broken down to small protein)
-Homemade hypoallergenic diets: no more than 2-3 months due to nutritional deficiencies if long term - Reduced-fat diets
-Ultra low-fat: dogs with PLE due to intestinal lymphangiectasia
-Low-fat: weight loss, chronic pancreatitis - Fiber supplementation
-Soluble fiber: metabolized by bacteria to form VFAs that are trophic to enterocytes
-Insoluble: increases fecal bulk, which stimulates motility and decreases spasms (gel-like) Not in obstipation or strictures cases - Caloric requirement: BER-Basal Energy Requirement = (BW kg) ^0.75 * 70
MER = RER * adjustment factor = kcal/day - Appetite Stimulants
-Mirtazapine
-Cyproheptadine
-Capromorelin: FDA approved dogs and cats with CKD and wt-loss
-Cobalamin supplementation may improve appetite in patients with low Vit B levels - Special nutritional management
-Enteral nutrition: use whenever posible
-Tube feeding: nasogastric/esophageal, pharyngostomy, esophagostomy, gastrostomy and enterostomy tubes
If not eating >3 days
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Q
A
25
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Parenteral nutrition: Bypass GIT
1. TPN: total parenteral nutrition
-IV solution that is customized and administered through a dedicated jugular IV catheter
2. PPN: partial parenteral nutrition; similar to TPN but provides only about 50% caloric requirements; can be given through a peripheral catheter
-Major disadvantages: risk of infection, cost, availability
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3. Describe and select the appropriate commonly used therapeutic agents/drugs used for gastrointestinal disease, in the following categories:
-Antiemetics
-Antacids
-Intestinal protectants
-Digestive enzyme supplementation
-Motility modifiers
-Anti-inflammatory/antisecretory drugs
-Antibacterials
-Probiotics/prebiotics
-Anthelmintics
-Enemas
-Laxatives
-Cathartics
1. Antiemetics
-Peripherally acting: kaopectate/bismuth subsalicylate (e.g. peptobismol). Aminopentaminde (Centrine)
-Centrally acting: Maropitant (Cerenia; NK-1 antagonist); Ondansetron (Zofran: 5-HT antagonist); Metoclopramide (Reglan; inhibits CRTZ, prokinetic); chlorpromazine proclorperazine (Compazine)
2. Antiacids
-Have some anti-dyspeptic effect
A. Acid titrating drugs
-Aluminum or magnesium hydroxide
B. Gastric Acid Secretion: inhibitors (H2 blockers)
-Cimetidine
-Famotidine
-Ranitidine
-Nizatidine
**Upregulation of receptors, so that acid "escape" occurs with long ther use
C. Proton pump inhibitors (PPIs) most effective ones
-Omeprazole (Prolisec)
-Iansoprazole
-Esomeprazole
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Intestinal Protectants
Which one forms an intestinal "bandage" on ulcerated mucosa?
-Form a local barrier coating
-Koalin
-Pectin
-Barium sulfate
-Sulcralfate: forms intestinal "bandage" on ulcerated mucosa
-Misoprostol: prostaglandin E-1 analog
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Pancreatic enzyme supplement
-Use to treat exocrine pancreatic insufficiency
-Powdered form works best
-Necessary to "incubate"
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Motility Modifiers
-Slow down
-Speed up
Slow Down
-Drugs that delay or shorten transient time in GI
-Diarrhea is often treated with them
**Opiate receptor agonist, caution in MDR gene dogs** Collie breeds, CNS signs, Naloxone reversal
-DIPHENOXYLATE
-LOPERAMIDE
Speed up - Prokinetics
-RANITIDINE
-NIZATIDINE
-CISAPRIDE - 5-TH4 agonist stimulates motility from lower esophageal sphincter to anus
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Anti-inflammatory - Antisecretory
Which one is beneficial for colitis?
How does Pepto-bismol (Generic name?) work?
What is the primary drug used for Inflammatory bowel disease?
Lessens fluid loss or controls inflammation
-Bismuth subsalicyclate (Pepto-bismol): antiprostaglandin activity of salicyclate
-Salicyazosulfapyridine: beneficial for colitis
-Olsalazine: lacks the sulfa component
-Corticosteroids: primary drug for moderate to marked inflammatory bowel disease
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Immunosuppressive
-Azathioprine dogs only
-Chlorambucil
-Cyclosporine
-Indicated to treat intractable IBD
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Antibacterial
-Only if high risk of infection
-Amoxicillin, metronidazole, and bismuth combination for Helicobacter gastritis
-Tylosin: for antibiotic responsive enteritis (ARE) and Clostridial Colitis
-Tetracycline for ARE
-Combination metronidazole and enrofloxacin for severe ARE
-Broad spectrum for sepsis: must have anaerobic and aerobic gram + spectrum
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Pro/Pre-biotics
-Probiotic: live bacterial or yeast supplement
-Prebiotic: specific dietary substance (fiber) that increases or influences the number of specific bacteria
-Veterinary products: Fortiflora, Proviable, Prostora
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Anthelmintics
Fenbendazole (Panacur, Safegard)
-Hookworms, Roundworms, Whipworms, Giardia
-Not approved for cats but often given with food for Giardia
-SID PO x3-5d
Metronidazole (Flagyl)
-Giardia
-Used in cats
Pyrantel
-H, R, P
-Dogs and cats
Ronidazole
-Giardia, Tritrichomonas
-Not approved for cats
Paryntel/febantel/Praziquantel (Drontal Plus)
-T, H, R, W
-Can treat Giardia
Imidocloprid/moxidectin (Advantage multi)
-Topical, follow label instructions
-H, R, W
Ivermectin/Pyrantel (HeartGard plus)
-H, R
Milbemycin (Sentinel, Trifexis)
-Not safe in dogs with D. immitis
-Not approved for cats
-H, R, W
Praziquantel (Drocit)
-T
-Echinococcus or Spirometra
Epsiprantel
-T
Sulfadimethoxine (Albon) / Trimethoprim-sulfadiaizine
-Coccidia
-May cause dry eyes, arthritis, various cytopenias, hepatic disease.
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Cathartics/ Laxatives
Enemas
-Retention
-Cleansing
-Hypertonic: do not use!
Cathartics and laxatives
-Bisacodyls (Dulcolax)
-Lactulose: osmotic, softening stool, can cause severe osmotic diarrhea, titrate to effect
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Lecture 6-7
Disorders of the Stomach 1-2
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1. Given PE findings and C/S of an affected C/F patient... Ddx list and initial diagnosis...
1. Acute Gastritis
-Huskies and Arctic breeds run for so long that they end up having acute gastritis at the end of a race
-Sudden onset of vomiting secondary to inflammation of gastric mucosa
-Acute bile, foam, blood, foreign material
Causes
-Dietary indiscretion/intolerance
-Drug or toxin ingestion
-Systemic illness
-Endoparatism
-Bacterial or viral
-Stress induced
Dx
-Diagnosis of exclusion based on thorough history and PE, and response to symptomatic treatment
-Concern if melena
-Rodenticides access
-Signs do not resolve within 2-3 days of symptomatic therapy
-Presence of hematemesis/melena
-Patient is systematically ill
-Abnormalities noted (pain) on abdominal palpation
Tx
-NPO for 12-24 hrs
-Fluid therapy SQ (~10ml/kg/site) or IV
-Crystalloids depending on level of dehydration
-Maropitant +/ ondansetron **only after ruled out forcing bodies**
-Addisonian patient rule out
-Offer ice first, then small amounts of water if no vomiting
-Add small meals of bland digestible diet
Classic Acute Diarrhea Syndrome
-Small breed dog
-Raspberry jam stool appearance Hematemesis and hematochezia
-Acute vomiting and hemorrhagic diarrhea
-Rapid course of disease quickly produces a critically ill patient
-No history of garbage/dietary indiscretion
-May be associated with Clostridium perfringes toxins (spores presence may be just forming due to abnormal environment, may not always need antibiotics)
-Ampicillin short term may be beneficial
-IV fluid most important
-Hemoconcentration >55% with normal to slightly decreased total plasma protein
-Other tests to rule out parvo, parasites, FB, others
Ddx: parvo enteritis, AHDS, HGE
Tx
-Aggressive IV fluids 20mls/kg
+/- Colloids
-Parenteral antibiotics: Ampicillin, metronidazole
-Antiemetic therapy
-Pain management
-Dietary management
-Nursing care frequent bathing to prevent rashes from inflammation perineal area
-Dextrose 2.5-5% or KCl supplementation
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2. Chronic Gastritis
-Intermittent or persistent vomiting/bile that lasts >7days and can not be attributed to underlying disease
-Systemic illness, weight loss, and GI ulceration are infrequent and should raise suspicion of a more serious condition or diffuse GI inflammation
-Ex: Golden Retriever 6-7 years old losing weight
Dx
-Radiographs plain/contrast
-Abdominal ultrasound
-Gastric biopsy for definitive diagnosis
-Additional test to rule out underlying disease (MDB, thyroid testing, cortisol/ACTH stimulation)
-Endoscopy to check the stomach
Ddx Categories of Chronic gastritis
-Lymphocytic-plasmacytic gastritis: immune/inflammatory reaction to antigens; Helicobacter-related)
-Tx: Low fat, low fiber, elimination diets (L-P gastritis)
-Eosinophilic gastritis: allergic reaction to food antigens. Cats likely
-Corticosteroids (prednisolone/prednisone), may be needed depending response to diet. PU/PD present, taper dose to lowest effective dose. Decrease dose by 50% tapering
-Chronic atrophic gastritis: chronic gastric inflammatory disease
-Granulomatous gastritis: Ollulanus tricuspis
Other Txs
-H2 antagonists or proton pump inhibitors
-Prokinetic therapy
Helicobacter-associated disease
-No clearly established relationship between
-Some animals are sensitive to this bacteria
Dx
-Cytologic exam
-Gastric biopsy of gastric mucosa
-Gastric mucosal urease activity
Tx
-Empiric
**Metronidazole, amoxicillin, bismuth for 14 days**
-Famotidine not necessary (only in humans) to eliminate organism
40
2.Given diagnosis plan results... establish a presumptive diagnosis for common gastric disorders
Gastric outflow obstruction
-Young siamese cats with projectile vomit
-Brachycephalic dogs
-Benign muscular pyloric hypertrophy (pyloric stenosis), closes up the lumen leading to mechanical obstruction
-Gastric astral mucosal hypertrophy
**Most common: Gastric foreign bodies, GDV**
-Partial or intermittent gastric volvulus and/or dilators. Dysbiosis within GI tract, VFAs not in balance leads to motility problems, acid being release
Pyloric Stenosis
-Unknown cause but may have relationship to elevated levels of gastrin (gastrictrophic hormone)
-Brachycephalics, siamese cats (esophagitis, regurgitation)
**Chronic vomiting and start regurgitating (may be projectile)**
-Cats may develop secondary esophagitis, megaesophagus and regurgitation
Dx
-Barium contrast. The thickness/obstruction causes barium to not pass quickly, >1 hr possible 24hr still in the stomach
-Radiographs limited value
-Gastroscopy
-Exploratory surgery
-Biopsy of pylorus should be performed to rule out infiltrative disease
-Endoscopy: get to the duodenum
-Ultrasound
Tx
-Surgery - pyloroplasty (Y-U_plasty)
Gastric Foreign Bodies
-Vomiting can result from gastric outlet obstruction, distention and irritation
-Cats less affected
-Anorexia possible, vomiting most common
Dx
-Radiographs
-Hx of acute onset of vomit, especially puppies, infection such as parvo
-Ultrasound
-Endoscopy
-Contrast radiographs
Tx
-Surgery
-Small objects may pass
-Induce vomiting if object unlikely to damage esophagus
-Removal by endoscopy (re-radiograph prior to anesthetizing to confirm location)
-Clevor: selective emetic with a fast onset of action and short duration of vomiting. Convenient single use dropper
GDV
-Great Danes 42% change of getting it
-Motility
-Thoracic conformation, deep chested
-Genetic predisposition
-Dietary factors (conflicting information)
-Large volume meal, once daily feeding, rapidly eating (aerophagia)
-Elevated feeding, dry food high in oil content
-Stomach fills with gas (dilation) and twists (volvulus) to produce GDV; some may need prophylactic surgery
-Volvulus causes a gastric outflow, obstructs portal vein and posterior vena cava, progressive distention
**That is why never catheters is back legs**
-Affected dogs retch unproductively, may pace and drool
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3. Develop a comprehensive treatment plan...
Pic foreign body
Emetic
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GDV
Dx
-Radiographs, Right lateral diagnostic if can't do any more
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GDV
Tx
-Aggressive fluid therapy for shock (cariogenic due to blood flow obstruction)
**16g catheters on each leg**
-Stabilize with orogastric tube or trochar decompression
-Follow with gastric lavage
-Systemic antibiotics **Cephazolin IV**
-Surgical exploration with necessary resection and gastropexy to prevent recurrence
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GDV
Post monitoring (Be ready to monitor)
-Cardiac arrhythmias VPCs. Tx: Lidocaine CRI
-Electrolyte imbalances (hypokalemia)
-Plasma lactate-biomarker in GDV as prognostic indicator, trends
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Bilious Vomiting Syndrome
Common
-Likely caused by gastroduodenal reflux when stomach is empty for prolonged period (e.g., overnight fast)
-Patient usually vomits bile-stained fluid once daily, at night or more typically in the morning prior to eating
Dx
-History and rule out underlying disease
Tx
-Feed twice daily, add gastric pro kinetic if needed (usually at bed time)
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Gastrointestinal Ulceration/Erosion
Common
-Common in working dogs, sporting dogs
Etiology
-Phychological stress in some dogs
-"Stress" ulceration, extreme exertion
-NSAIDS*
-Neoplasia (e.g., mast cell tumors and gastrinomas)*
-Hepatic failure, IBD, infiltrative disease (pythiosis)
Dx
-C/S
-Inappetance common
-Blood in vomitus
-Anemia with weakness
+/- pain on abdominal palpation
-Signs of septic peritonitis if perforation occurs
Dx
-History and PE
-Signs of GI blood loss on CBC
-Serum biochemistry
-Endoscopy is diagnostic test of choice, most sensitive for identifying GUE and for infiltrative lesions
-Biopsy of mucosa
-Abdominal ultrasond: thickened gastric wall and an obvious defect representing an ulcer
Tx
-Symptomatic therapy in most cases but depending on the underlying cause
-Antiacid therapy (PPIs most effective but can use H2 receptor antagonists)
-Gastroprotectans (sucralfate)
Prevention
-Rational NSAIDs and steroid therapy
-PPIs in working/sled dogs
-Misoprostol decreases occurrence of NSAID induced GUE
48
Gastric Neoplasia
-Can cause GUE secondary to mucosal disruption and include:
Dogs
-Adenocarcinomas
-Lyphoma
-Leimyomas, leiomyosarcomas and stroll tumors
Cats
-Lymphoma
C/S
-Often asymptomatic until advanced disease
-Vomiting due to outflow obstruction
-Hematemesis
-GUE associated with infiltrative disease
-Weight loss +/-
Dx
-Iron deficiency anemia
-Plain and contrast radiography
-Abdominal ultrasound
-Endoscopy can identify most tumors
-Biopsy of masses
-CBC: microcytic, hypochromic, and either regenerative (acute) or non regenerative anemia (chronic)
Tx
-Depending on the tumor type
-Surgical resection is difficult in many cases
-Most adenocarcinomas are advanced and unable to get surgical margins
-Leiomyomas/leiomyosarcomas most resectable masses
-Chemotherapy most effective for lymphoma
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Cases
50
Cases
51
Cases
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Lecture 8
Disorders of the Intestinal Tract 1
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Learning objectives
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Acute enteritis
-Catch all-can be serious or mild
Etiology
-Not usually found cause, but can be infectious agents, poor diet, abrupt dietary changes, inappropriate foods, additives (e.g., chemicals) and/or parasites.
-Common especially in puppies and kittens
C/S
-Diarrhea with our without vomiting
-Dehydration
-Fever
-Anorexia
-Depression
-Crying
+/- abdominal pain
Dx
-Primarily based on history and clinical presentation
-Rule out parasites
-Rule out infectious dz, foreign body, other systemic disease
Tx
-If mild often symptomatic and supportive
-Fluid therapy: correct electrolyte imbalances +/- dextrose
-Antidiarrheals: not always recommended; opiates (e.g., Loperamide) are best option, if needed
-Probiotics: have been shown to shorten duration of diarrhea
-Broad spectrum antibiotics if neurogenic, febrile
-Antiemetics: maropitant, ondansetron - centrally acting
-Old school withhold food to "rest" the intestinal tract
-Administering small amounts of food
-Bland, highly digestible diet
**Exception: temporarily withhold food if eating causes severe vomiting or explosive diarrhea with substantial fluid loss**
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Dietary-Induced Diarrhea
Etiology
-Common, especially in young cats and dogs
-Rapid diet changes, poor quality ingredients
-Dietary allergy or intolerance
C/S
-SI diarrhea signs
-Sometimes colonic involvement
-Mild to moderate diarrhea beginning 1-3 days after dietary change
Dx
-Based on history and clinical presentation
-Perform a fecal flotation
Tx
-Bland, highly digestible diet in multiple small feedings
-Diarrhea should resolve in 1-3 days
-Reevaluate the patient if not improved
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Canine Parvovirus
Etiology
-CPV-1: relatively nonpathogenic, gastroenteritis, pneumonitis, and or myocarditis in puppies 1-3 weeks old
**CPV-2**
-Responsible for classic parvovirus enteritis
-Strains: 2a, 2b, 2c (most common and vax not as effective if <6 weeks to 6 mts of age
-Fecal-oral route
-Signs 5-7 days post exposure
-Preferential for intestinal crypts cells and bone marrow stem cells
-Severity depends on the virulence, size of inoculum, host defenses, age, and concurrent parasites/health status
**Most common cause of vaccine failure is interference from maternal antibodies**
-Doberman Pinschers, Rottweilers, Pitbulls, Labrador Retrievers and GSD more at risk
C/S
-Vomiting: prominent and may be severe
-Diarrhea: within 24-48 hrs +/- blood
-Intestinal protein loss secondary to enteritis
-Sepsis may occur secondary to bacterial translocation across compromised intestinal mucosa
-Fever
-SIRS may follow
-Myocarditis <8 wks old
Dx
-SNAP test
-ELISA parvo SNAP test requires adequate fecal viral shedding
-Neutropenia
-Lymphopenia
-Thrombocytopenia
-Hypoproteinemia
-Hypoglycemia
-MLV can interfere with testing ~10 days
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Canine Parvovirus Treatment
Fluids
-Balanced electrolyte solution with 30-40 mEg potassium chloride
-Estimated maintenance + estimated deficit
-Add 2% dextrose
-Plasma or hetastarch if dog has serum albumin concentration <2g/dl
-Plasma 6-10ml/kg over 4 hrs; repeat until desired serum albumin attained
-Hetastarch 10-20 ml/kg (generally not combined with plasma)
Antibiotics
-Administer to febrile or severely neutropenic dogs
-Broad-spectrum B-lactams for gram + and anaerobic, plus gram (-) amikacin or enrofloxacin
Antiemetics
-Maropitant or Ondansetron (if <11-16 weeks)
-Metoclopramide CRI very effective
Anthelmintics
Antidypeptics/Antiacids
Secondary esophagitis: PPIs
Special Nutrition
-Small amounts
-Avoid exacerbation in vomiting
-Microenteral (slow drip of enteral diet via nasoesophageal tube)
-Parenteral nutrition if prolonged anorexia occurs
Monitor physical status
-PE 1-3 times per day
-BW
-Serum protein
-Glucose
-PCV
-WBC count
Monoclonal Antibody
-Chimeric monoclonal antibody
-Single IV injection
-Binds circulation CPV-2
-Results in neutralization of the virus
-Prevention of viral infiltration and destruction of enterocytes
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CPV-2 Common Therapeutic mistakes
-Inadequate fluid therapy
-Overzelous fluid therapy
-Failure to check blood glucose and supplement if hypoglycemic
-Failure to add adequate KCL to fluids
-Failure to recognize sepsis
-Failure to find concurrent GI disease (e.g., intussusception)
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Other Viral Diarrheas
-Canine Coronavirus
-Feline coronavirus
-Feline Parvovirus (Feline panleukopenia virus)
-Feline leukemia virus associated panleukopenia
-Feline immunodeficiency virus associated
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Bacterial and Fungal Diarrheas
**Bacterial all may be found in feces from normal dogs and cats**
-Campylobacteriosis
-Salmonellosis
-Clostridial disease
Fungal
-Histoplasmosis
-Protothecosis
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Campylobacter
Campylobacter jejuni
-GI disease strain
-<6 mots old
-Crowded conditions
-Self-limiting mucoid diarrhea
Dx
-"Seagull wings or comma" forms on cytology
-PCR
Tx
-Erythromycin, neomycin, fluroquinolones are effective
**Potential zoonosis**
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Salmonellosis
-Salmonella enterica serovars uncommon
-Fecal-oral route
-Feeding raw diet, poultry, eggs
C/S
-Acute/chronic diarrhea, septicemia, death in young/old
Dx
-PCR, blood culture
-Positive fecal culture is not necessarily diagnostic
Tx
-Supportive therapy
-Fluids, +/- plasma or colloids
-Probiotics
-Antibiotics in septic animals
**Potential zoonosis**
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Clostridial Disease
-Clostridial perfringens and C. difficile
-Can be found in normal dogs; bacteria must produce enterotoxin
C/S
-Acute hemorrhagic diarrhea
-Chronic small and or large bowel diarrhea
Dx
-Enterotoxin assay definitive diagnosis
Tx
**Tylosin or Amoxicillin**
-Response expected 2-5 days
-Probiotics, fiber supplementation
-No public health concerns
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Histoplasmosis
-Fundal disease associated with Histoplasma capsulatum
-Regional importance
C/S
-Infiltrative bowel disease (colon) dog
-Cat respiratory involvement
-Other symptoms may be present: bone, LNs, spleen, bone marrow, ocular lesions
-Important to rule out fungal infection prior to starting immunosuppressive therapies
Dx
-Weight loss
-PLE
-Large bowel diarrhea
-Thickened rectal mucosa
-Yeast in rectal mucosal scraping/bx
-Urine yeat
-ELISA Ab test
Tx
-Itraconazole
+/- amphotericin B for 4-6 months
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Lecture 9
66
Intestinal Parasites
1. Whipworms - Trichuris vulpis
C/S
-Colitis
-Diarrhea
-Hematochezia (passage of fresh blood LI)
Dx
-Based on clinical signs
-Zinc flotation
-May require multiple flotations to diagnose (e.g., occult parasitism)
Tx
-Febantel
-Fenbendazole
-Milbemycin
-Moxidectin (topical)
-Treat monthly for 3 months
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2. Roundworms
C/S
-Normal to mild/moderate SI diarrhea
-Vomiting worms
-Stunted growth
-Roundworm "potbelly"
Dx
-Easily found on zinc flotation fecal
Tx
-Fenbendazole
-Milbemycin
-Moxidectin
-Piperazine
-Pyrantel (dogs)
-Emodepside
-Selamectin (cats)
**Treat before 3-4 mts old puppies, and annually**
**Zoonosis: ocular visceral larval migraines**
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3. Hookworms - Ancylostoma ssp, Uncinaria spp.
C/S
-Ingestion of ova
-Transcolostral
-Penetration of larvae
-Blood loss with associated anemia
-Melena
-Hematochezia
-Diarrhea
-Failure to thrive
Dx
-Zinc sulfate fecal flotation
Tx
-Fenbendazole
-Moxidenctin
-Paryntel
-Milbemycin (dogs)
-Selamectin (cats)
-Emodepside
-Ivermectin
**Zoonosis, cutaneous larval migraines**
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4. Tapeworms - Dipylidium caninum, Taenia spp, Exhinoccocus spp.
C/S
-Rarely pathogenic
-Associated with anal itching
-Large numbers may obstruct intestines (rare)
Dx
-Visualize proglottid segments
-Detected on routine flotation
Tx
-Epsiprantal and praziquantel
-Flea control
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5. Coccidiosis - Cytoisospora spp
C/S
-Mild to severe diarrhea
+/- Blood in young cats and dogs
Dx
-Oocysts on fecal flotation
Tx
-Sulfadimethoxine
-Trimethoprim sulfa
-Amprolium and Toltrazuril (off label)
-Environmental control
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6. Cryptosporidia - Cryptosporidium parvum
C/S
-Diarrhea in young dogs <6mts and cats adults
Dx
-Fecal flotation
-Cysts identification on flotation
-Very small cysts
-ELISA
-PCR
-IFA available
Tx
-Azithromycin, but nor reliably consistent
-Look for immunosuppression in the host
-Animals develop immunity
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7. Giardiasis - Giardia spp
C/S
-SI usually diarrhea
-Mild to severe diarrhea, "cow patty"
Dx
-Motile trophozoites in fresh feces warm saline mounts
-Cysts on zin-sulfate fecal flotation
-Fecal ELISA (SNAP giardia test)
-Can be difficult to find
Tx
-Fenbendazole for 5 days
+/- Metronidazole
-Easily re-infected from environment
**Zoonosis A&B**
-Clean off crusty butt area
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8. Trichomoniasis - Tritrichomonas spp
C/S
-Cats are affected
-Exotic cat breeds
-LI diarrhea
+/- Blood
Dx
-PCR most sensitive
-Fecal culture rarely used
-Identifying motile trophozoite
Tx
-Can be difficult
-Ronidazole, neurological signs possible
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Maldigestive Disease
1. Exocrine pancreatic insufficiency
Etiology
-Pancratic acing atrophy or destruction due to pancreatitis
C/S
-Inability to digest food
-Chronic SI diarrhea
-Steatorrhea (diarrhea with undigested fat)
-Slate-gray stools
-Ravenous appetite
-Weight loss
Dx
-Trypsin-like Immunoreactivity (TLI) is the most sensitive and specific
Tx
-Supplementation of pancreatic enzymes
Causes
-Histoplasmosis
-Pythiosis (Pythium insidious organism) found in water
-Dietary responsive - allergies, intolerance
-Cats: neoplastic, parasitism: giardiasis.
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Dietary Responsive Diarrhea
Etiology
-Allergic reaction to dietary antigens (protein antibodies) immune mediated or intolerance of dietary compounds (non-immune)
C/S
-Vomiting
-Diarrhea (SI or LI)
+/- skin disease
Dx
-Rigorous step by step elimination diet
-IgE testing not as sensitive or specific
Tx
-Strict adherence to hypoallergenic diet
-Limited antigen diets - single novel source protein source
-Hydrolized diets good choice
-Avoid high-fat diets
-Most dogs and cats respond within 3 weeks
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Antibiotic Responsive Enteritis - Dysbiosis
Etiology
-Bacterial overgrowth in duodenum and/or jejunum
-Abnormal host response to the bacteria
-E.coli, enterococci and anaerobes especially common
-Dysbiosis
C/S
-Diarrhea
+/- Weight loss
+/- Vomiting
Dx
-Poor specificity and sensitivity tests, best based on response to treatment
Tx
Antibiotics
**Tylosin, Metronidazole or Metronidazole + Flouroquinolones**
-Combination for resistant cases
-3 weeks minimum course
Elimination diet
-Hypoallergenic/hydrolyzed diets
-Goal is to control not to cure
-Fecal transplantation becoming more popular and successful
**70% of dogs with chronic diarrhea likely Diet-responsive, 15% likely ARE**
-Some need both
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Chronic Enteropathy patients Therapeutic Sequence (Strict)
1. Eliminate parasites
2. Diet trials-start hydrolyzed for 3 weeks, if fails then novel protein
3. Supplement cobalamin-safe and easy
4. If not improving then antibiotics such as Tyrosine and continue the elimination diet for 3 weeks
5. If this fails then biopsy, fecal transplantation or probiotics
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IBD
Etiology
-No universally accepted definition
-Disease of exclusion (e.g., idiopathic)
-Inapropriate response of intestinal immune system that evolves into a self-perpetuating state of inflammation
**Lymphocytic-plamacytic enteritis IBD is the most commonly diagnosed form in dogs and cats**
C/S
-Vomiting
-Chronic SI diarrhea
-Weight loss is classic
-PLE only if severe
**Closely resembles small cell alimentary lymphoma in the cat**
Dx
-Exclusion of other diseases
-Biopsy
-Histologic diagnosis (full thickness)
-Hypoproteinemia when severe
-Evaluate cat for triaditis if severe IBD
Tx - Dogs
-Mild: maybe dietary or antibiotic responsive
-Add immunosuppressive therapy
-Prednisone, Budesonide, Azathioprine, Chlorambucil or Cyclosporine
-Cobalamin supplementation
Tx- Cats
-Similar dietary management
-Metronidazole
-Prednisolone
-Budesonide
-Chlorambucil
-Cobalamin
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Intestinal Lymphangectasia
Etiology
-Common PLE
-Primarily affects dogs
-Lymphatic obstruction results in dilation and rupture of the intestinal lacteal
-Yorkshire terries, Soft-coated Wheaten Terriers and Lundehunds increased risk
C/S
+/- Diarrhea
**Severe hypoalbuminemia (<2g/dl)**
-Hypocholesterolemia
-Leakage of protein, lymphocytes and chylomicrons
Dx
-Histopathology
-Endoscopy
Tx
-Ultra-low fat diet
+/- anti-inflammatory or immunosuppressive therapy
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Intestinal Obstruction
1. Simple intestinal obstruction
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2. Incarcerated Intestinal Obstruction
85
3. Mesenteric Torsion/Volvulus
86
4. Linear Foreign Body
87
5. Intussusception
**Ileocolic most common site, ileum entering the larger intestine colon segment**
-Often associated in young animals with enteritis, parasites, etc. that alter GI motility
-Typical signs of obstruction; chronic intussusception may cause intermittent signs as segment slides in and out
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Large Intestine Inflammation
1. Acute colitis/Proctitis
2. Chronic Colitis - LI IBD
3. Granulomatous/Histicytic Ulcerative Colitis (Boxer colitis)
**Careful with corticosteroids use when IBD**
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Acute Colitis
Etiology
-Many causes: bacteria, parasites, diet, etc
-Common dogs>cats
C/S
-LI diarrhea
-Tenesmus
-Mucus
-Hematochezia
Dx
-Rectal exam: rule out underlying disease
Tx
-Treat underlying disease
-Symptomatic therapy: bland diet +/- fiber
-Canned pumpkin or metamucil
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Chronic Colitis
-Chronic LI diarrhea
-Many underlying causes
-Parasites, fiber, diet, responsive disease, etc.
-Lymphocytic-plasmacytic colitis can cause it
Dx
-Rule out underlying disease
-Colonoscopy and biopsy id definitive
Tx
-Fiber enriched diets
-Hypoallergenic diets
-Metronidazole
-Sulfasalazine (dogs)
-Steroids
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Rectal Prolapse
-Can occur with straining from diarrhea & parasites
-Manx cats have a sacrocaudal dysgenesis
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Perineal/Perianal Disease
Perineal Hernia
-Pelvic diaphragm weakens
-Intact dogs
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Anal Sacculitis
-Inflammation and secondary infection of the anal sacs
-Rupture and drain purulent material
-Occasionally bleed onto the feces
-Clean and flush as needed
-Oral antibiotics 7-14 days until resolved
-Antibiotic-steroid ointment infuses
93
Perianal fistulae
-Very painful
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Neoplasia
Small Intestine
-Alimentary Lymphoma (common in cats)
-Intestinal Adenocarcinoma
-Intestinal Leiomyoma/Leiomyosarcoma/Stromal Tumor
Large Intestine
-Adenocarcinoma
-Rectal polyps
-Anal Sac (Apocrine Gland) adenocarcinoma
-Perianal Gland tumors
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Constipation
-Any perineal disease: fistulae, hernia, anal sacculitis
-Pelvic canal obstruction due to pelvic fracture and narrowing
-Dietary indiscretion
-Idiopathic megacolon
Tx
-Multiple warm water retention and cleaning enemas over 2-4 days
-Add fiber to moist diet (metamucil or pumpkin pie fillin)
-Keep litter box clean and accessible
-Osmotic laxatives (lactulose) and or pro kinetic drugs (cispride)
-Need IV fluids
-Careful with cardiac disease in cats
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Lecture 10
Disorders of the Peritoneum
97
Septic Peritonitis
-Usually caused by leakage from GI or biliary tract
-Occasionally from other organs such as uterus (pyometra with rupture) or liver (abscesses)
Dog
-GI perforation
-Neoplasia GI
-Ulceration GI
-Intussusception
-Foreign bodies
-Surgery site dehiscence
-Bile leakage: necrotizing cholecystitis (mucocele or chronic bacterial infection)
Common organisms associated with secondary septic peritonitis - enteric organisms such as:
-Escherichia coli
-Bacteroides spp
-Clostridium spp
-Klebsiella spp
-Enterococcus spp
**E. coli the most commonly associated in bile peritonitis**
Abdominal trauma - Dog
-Penetrating wounds
-Gunshots
-Surgery
Cat
-Abdominal trauma
-Bite wounds
-Hit by car
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Septic Peritonitis - PBP
Primary
-Spontaneous bacterial peritonitis
-No underlying cause identified
-Oral bacteria suspected or translocation from intestines
-Gram positive organisms more commonly present in PBP
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Post operative peritonitis
-Generally, 3-6 days post-op
-Increased risk factors: hypoalbuminemia (<2.5 g/dL)
-Intestinal foreign body
-Pre-existing peritonitis
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Septic Peritonitis
C/S
-Mild vomiting
-Inappetence
-Fever
-Abdominal pain to severe systemic involvement
-Abdominal effusion mild to moderate, some large amounts
-Dogs with PBP tend to have more abdominal effusion
Dx
-Clinical suspicion
-Neutrophilia
-Neutropenia + hypoglycemia
-Decreased sereosal detail on abdominal films
-Free air in the abdomen
-Ultrasound is the best tool for evaluating and detecting small amounts of fluid
**Abdominocentesis**
-Culture
-Cytology
-Exudate, high protein, degenerative neutrophils, high cell counts.
-Bacteria phagocytized by WBCs
-Fecal material in fluid
-Cells and bacteria may be difficult to find in small amounts of fluid
-Diagnositc peritoneal lavage may be needed to collect more fluid
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Septic peritonitis - Tx
Tx
-PBP usually don't benefit from sx, may try to manage medically with antibiotics (Clavamox) and supportive care
-Secondary: commonly surgical management + supportive care
-Initial antibiotics broad spectrum, parenteral
-Ticarcillin/clavulanic acid + metronidazole + amino glycoside or enrofloxacin
-IV fluids and colloid
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Hemoabdomen
-Abdominal fluid with a hematocrit of 10-15% or greater
Causes
-Iatrogenic (abdominocentesis)
-Traumatic (HBC, splenic rupture)
-Coagulopathies (rodenticide toxicity)
-Spontaneous diseases (bleeding neoplasia, HSA)
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Hemangiosarcoma
-In older dogs
-Golden Retrievers, GSD
-Acute and or periodic hemorrhage from splenic HAS
-Episodes of weakness (can be regenerative anemia)
-Abdominal effusion (hemorrhagic)
-Bicavitary effusion may be seen
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Abdominal Carcinoma
-Widespread military peritoneal carcinomas
-Various sources: e.g., intestinal and pancreatic adenocarcinomas that "seed" the abdominal cavity
-Weight loss is primary complaint
-Abdominal effusion - non-septic exudate or modified transudate; occasional neoplastic cells
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Carcinomatosis
-Prognosis is poor to grave
-Identify and treat underlying neoplasia
-Intracavitary chemotherapy may be palliative (cisplatin/5-fluorouracil or carboplatin)
-Referral
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