Approach to GI disease and localization

What are the different anatomic localizations of GI disease?

Primary vs secondary GI disease

Oropharyngeal vs esophageal vs gastric vs SI vs LI vs mixed

What are the temporal classifications of GI disease?

Acute or chronic

What are mechanisms of diarrhea?

Osmotic, secretory, dysmotility, exudative

What do you want from a history?

Signalment, vax/deworming, duration, frequency, diet, travel history

If a patient is vomiting what are some followup questions?

Associated with eating or drinking?

Time of last bowel movement?

Concurrent diarrhea?

What do you want to to find on PE for GI dz?

Dehydration, fever, abdominal pain, BCS, signs of systemic dz (oral ulcer, icterus)

Where is a primary GI disease located?

Oral/pharngeal, esophageal, gastric, intestinal, rectoanal

What are some signs of oral disease?

Difficult prehension, food bolus formation, chewing abnormalities

What is pharyngeal/cricopharyngeal disease?

Impaired passage of food through oropharynx

What happens during esophageal disease?

Impaired passage of food through body of esophagus into stomach

What are signs of pharyngeal/cricopharyngeal disease?

Gagging and immediate food reflux

Regurgitations points you to what part of the GI tract?

Esophagus

What is regurgitation?

Passive process without vomiting movements like lip-licking, retching, contractions

Silent

Inability to predict timing

Undigested food

No bile

Vomiting 8-10 hours after eating suggests what?

Delayed gastric emptying

What are signs of gastric disease?

Vomiting

Also nausea, ptyalism, dysrexia, belching, abdominal distention, cranial abdominal pain, weight loss w/ decreased intake

What are signs of intestinal disease?

Diarrhea

Also nausea, vomiting, diarrhea, constipation, weight loss

Diarrhea that is normal to slightly increased frequency of defecation, large volume, and lack of urgency indicate?

SI diarrhea

What can SI diarrhea also have visually?

Melena, flatulence, steatorrhea, concurrent vomiting, weight loss

Diarrhea that has increased frequency, small volume, urgent, tenesmus is what?

LI diarrhea

What can LI diarrhea also have visually?

Hematochezia and or mucus

SI diarrhea

LI Diarrhea

What does rectoanal disease look like?

Dyschezia, tenesmus, mucoid or hemorrhagic discharge

Ribbon like stool

Blood on outside of feces

What is dyschezia?

Difficult or painful defecation

What is your diagnostic approach for acute GI disease with mild C/S?

Nothing if you think it was a one time thing

Check hydration, fecal float, rule out other things like foreign body

When do you do radiographs for an acute animal with mild C/S signs?

Lack of bowel movement

Foreign body

Non-productive retching

Abdominal distension

When do you always want additional diagnostics for an acute vomiting/diarrhea animal?

Dull/depressed, fever, tachy or brady cardia, abdominal pain, melena, severe signs, mild case that was unresponsive to symptomatic therapy

What are some rapid initial tests for an acute animal with moderate or severe or systemic signs?

Hydration (PCV/TS)

POC electrolytes

CBC, chem, urinalysis

Radiographs to determine if surgery is needed

What are some tests that you do on a case-by-case basis depending on presentation?

Parvovirus SNAP

Fecal float

Blood pressure

Cortisol ± ACTH stim

Coag test

What is an important thing when diagnosing chronic disease?

Exclusion of non-GI disease

Rule out infectious disease

Usually will do abdominal imaging

What are some good tests to exclude non-GI disease?

CBC/chem, urinalysis, baseline cortisol (dogs), T4 in cats, spec PL, bile acids

How can you exclude infectious diseases?

Fecal float and deworming

Describe the value of abdominal imaging in chronic cases?

Non-specific, can get decreased serosal detail if effusion or thin, gas or fluid distension if decreased motility

Describe the value of abdominal ultrasound with chronic cases

Very good, can evaluate intestinal wall changes, lymph nodes, GI masses or chronic FB, effusion gas/fluid GI distension

What are some intestinal wall changes with chronic GI disease?

Increased thickness

Decreased layering

Mucosal hyperchogenicity

How often is abdominal ultrasound normal in patients with idiopathic chronic enteropathies?

30%

What does the GI panel establish?

Rules out pancreatic disease

Localizes to GI

Defines disease severity

Determine need for supplement

What are the tests in a GI panel?

Cobalamin

Folate

Pancreatic specific lipase

Trypsin-like immunoreactivity

What does hypocobalaminemia indicate?

Ileum malabsorptive disease

R/o exocrine pancreatic insufficiency

What does decreased folate indicate?

Proximal SI disease

When do you biopsy the GI tract?

Typically chronic diseases with clinical parameters of inappetence, lethargy, progressive weight loss, treatment trial failure

Diagnostic indicators for biopsy are hypoalbuminemia, hypocobalaminemia, suspicion of infectious or neoplastic cause

Why should you always biopsy prior to steroids?

Steroids can alter biopsy results

What can you definitively diagnose with a biopsy?

Needed for idiopathic inflammatory enteropathies

Usually get lymphoplasmacytic

What can you find on a biopsy to point you in other directions?

Neoplasia concern

Neutrophils can make you consider FISH, campylobacter in cats

Eosinophils can make you repeat deworm or a food trial

Pyogranulomatous can make you search for fungal or atypical bacteria

Low fat diet in yorkies

What are some limitations of GI biopsies?

All inflammatory patterns can be seen with idiopathic chronic dz

Do not differentiate between treatment responses

histopath does not correlate with C/S seveity

Microscopic changes do not resolve with treatment