Lectures 10-16

What are clinical signs of abdominal pain?

• Decreased appetite

• Abnormal posture (stretching, arched back)

• Kicking at the abdomen

• Repeatedly lying down and getting up

• Restlessness

• Lethargy

What clinical signs of abdominal pain are more common in SA?

• Tender/tense on abdominal palpation

• Reluctant to move, stilted gait

• Whine

• Excessive salivation

• Play / prayer pose

What clinical signs are more common in ruminants?

• Grinding teeth (bruxism)

• Grunt/groan

• Abdominal distension

What clinical signs of abdo pain are more common in horses?

• Colic

• Pawing

• Sweating

• Quivering upper lip

• Flank watching

• Kicking at abdomen

What GI mechanisms cause abdominal pain?

• Distention / stretch of intestinal wall

• Mesenteric tension

• Inflammation

• Ischemia

• Spasm

• Deep mucosal ulceration

What are some non-obstructive causes of colic?

• Spasmodic / gas colic

• Proximal enteritis

• IBD

• Colitis

• Sand (can be obstructive)

• Peritonitis

• Gastric ulcers

What are some simple obstructive causes of colic?

• Stomach impaction - rare

• Small intestinal impaction - ileum

• Ascarid impaction - foals

• Eosinophilic enteritis - mural bands

• Large colon impaction - common

• Large colon displacement - R/L dorsal

• Enteroliths - alfalfa diet

• Cecal impaction

• Small colon impaction

What are some strangulating causes of colic?

• Strangulating lipoma of small intestine

• Small intestinal volvulus

• Mesenteric rent

• Epiploic foramen entrapment

• Gastrosplenic entrapment

• Intussusception

• Large colon torsion

• Strangulating lipoma of small colon

What is the diagnostic approach to abdominal pain?

• Obtain a complete Hx

• Perform a thorough PE

• Eq: Rectal exam & NG tube

• Assess severity

  • Cardio status, GI condition, recurrent signs of pain

• Observe response to pain meds (fasted)

• More advanced Dx PRN

• Diagnosis → does p need surgery?

What are history questions or ask for abdo pain?

You already know this so here’s a picture lol

How do you perform a PE for abdo pain?

• General appearance

• Grade pain level if present

• BCS & weight

• General PE

  • TPR

  • Hydration/perfusion

  • GI auscultation / percussion

  • Eq: digital pulses

  • SA: abdo palpation

What diagnostics can you run for abdominal pain?

• Blood gas

• CBC/Chem

• Imaging

• Abdominal fluid analysis

• Rectal palpation

• NG tube for LA

What is the treatment for abdominal pain?

• Remove feed

• Control pain

• Supportive care

• Identify and treat primary dx

• Surgery PRN

What are indications for surgery in patients with abdominal pain?

• Diagnosis of strangulating lesion

• Intestinal obstruction that does not respond to medical therapy

• High level of pain / persistent pain

What is abdominal distention?

Enlargement of the abdomen due to various causes including:

• Pregnancy

• Obesity

• Accumulation of fluid or gas

• Accumulation of ingesta

• Organomegaly

• Mass

What is the definition of constipation?

Infrequent or difficult evacuation of hard, dry feces

What are causes of constipation?

• Dietary - low fiber, indigestible material

• Dehydration - decreased intake or increased loss

• Obstruction - mechanical or functional

What are treatments for constipation?

• Fluid therapy

• Laxatives, cathartics

• Address primary problem

What is colic?

A broad term referring to abdominal pain in horses, characterized by pawing, abdominal distention, sweating, etc.

Define tenesmus

Ineffective and repeated straining at defecation (or urination) resulting from disease of the large intestine or lower urinary tract

Define dyschezia

Difficult and/or painful evacuation of feces due to disease of the anus and perianal tissue

What are causes of tenesmus?

• Inflammatory condition of lower GI

• Hepatic failure (ruminants and horses)

• Rectal Dx

• Reproductive

• Urinary - urolithiasis

What can tenesmus result in?

Rectal collapse

Define dysphagia

Difficulty or painful swallowing due to oral or pharyngeal disease

Define regurgitation

Passive retrograde expulsion of food or fluid from the oral/pharyngeal cavity or esophagus, not involving abdominal muscles.

Define vomiting

Forceful ejection of food or fluid through the mouth, from the stomach or proximal duodenum, involving abdominal muscle contraction

What does swallowing require?

• Normal tongue and pharyngeal muscle motility

• Normal innervation of tongue, pharynx, larynx, cricopharyngeal m., and upper esophagus

• Need to sense bolus

How is swallowing initiated?

By voluntary passage of bolus into retropharynx. Once food is in pharynx, an involuntary pharyngeal phase is triggered

Swallowing is a complex reflex action requiring coordination of what 4 things?

• Anatomic structures

• Cranial nerves VII, IX, X, XII

• Brain stem

• Swallowing center in brain (medulla)

What are the 3 phases of swallowing?

1. Oropharyngeal

2. Esophageal

3. Gastroesophageal

What is the oropharyngeal phase?

The first phase of swallowing, comprising the oral (voluntary), pharyngeal (involuntary), and cricopharyngeal subphases

What occurs in the pharyngeal subphase of swallowing?

• Contractions move bolus from tongue to cricopharyngeal passage

• Soft palate is pulled upwards

• Vocal cords approximated, epiglottis closes

• Larynx is pulled cranially and ventrally

  • Begins opening of UES

What happens in the esophageal phase of swallowing?

Primary and secondary peristaltic waves move bolus

Define dysphagia

Difficult or painful swallowing; trouble when picking up food and forming a bolus

What are causes of dysphagia?

• Pain during prehending or swallowing process

• Mechanical obstruction of the oral cavity or pharynx

• Neuromuscular dysfunction

Pharyngeal and cricopharyngeal dysphagia often accompany __________ ________ disorders

esophageal motility

What is an important zoonotic differential to keep in mind for dysphagia?

Rabies!

What are clinical signs of dysphagia?

• Can have decrease or absent appetite

• “Strange behavior” → turkey poking or gobbling

• Dropping food while eating

• Tilted head back

• Chewing on one side

What are some common causes of dysphagia?

• Congenital defects

• Dental, periodontal Dx

• Trauma

• Inflammatory Dx

• FB

• Neoplasm

• Disease - botulism, masticatory myositis, rabies, tick paralysis, etc.

What immune mediated Dx in cats can cause oral dysphagia? What do those cats commonly have that causes this?

Feline Lymphoplasmacytic Stomatitis;

Commonly have FIV ± calici virus

What is Feline Lymphoplasmacytic Stomatitis?

Severe lymphocytic / plasmocytic inflammation of gingival, periodontal structures, and pharynx

What is the treatment for Feline lymphoplasmacytic Stomatitis?

• Partial or full-mouth tooth extraction

• Medical management: antimicrobial, anti-inflammatory or analgesic medications

What is a Ranula?

A sublingual mucocele caused by rupture of sublingual salivary duct that causes accumulation of saliva and mucus at the base of the frenulum

How does a ranula cause dysphagia?

Accumulation of saliva causes inflammatory and fibrous tissue which prevents normal tongue function

What is the treatment for a ranula?

Excising a portion of sublingual mucosa overlying the mucocele and suturing the rim of the oral mucosa to connective tissue ± removal of the mandibular and sublingual salivary glands

Define pharyngeal dysphagia

Trouble with the tongue bringing bolus back to the pharynx. Swallowing starts but is not completed

What is the diagnostic for pharyngeal and cricopharyngeal dysphagia?

Often distinguished with fluoroscopy

Define cricopharyngeal dysphagia

No relaxation of cricopharyngeal muscles. Problems with muscle that forms much of the UES

What are the 2 most common causes of pharyngeal and cricopharyngeal dysphagia?

Congenital abnormalities and neurological diseases (see picture for others)

When examining a patient with dysphagia, you need to watch them eat. How will a patient with oral dysphagia eat?

Difficulty BEFORE swallowing. Animal may tilt or throw head back while eating and drop food

When examining a patient with dysphagia, you need to watch them eat. How will a patient with pharyngeal dysphagia eat?

Chew normally. Repeated attempts to swallow, often with flexing and extending of neck

When examining a patient with dysphagia, you need to watch them eat. How will a patient with cricopharyngeal dysphagia eat?

Start to swallow then cough or gag. Bolus enters cricopharyngeus but it does not relax, bolus hits larynx and initiates cough

What diagnostics are performed for the dysphagic patient?

• Complete PE

• Neuro exam

• Survey rads

• CBC, Chem, UA

• Contrast fluoroscopy motion study / endoscopy

How do you treat a dysphagic patient?

• Identify and eliminate underlying disorder

• Feeding tubes may be necessary at times

• Treat secondary complications

Define regurgitation. What does it produce?

Passive expulsion of gastric or esophageal contents resulting from local mechanical events within esophagus.

Produces undigested food, tubular shape, and frothy saliva.

What helps determine if regurgitation is proximal or distal? Explain each.

Timing helps determine location of problem:

• Proximal = immediately after eating

• Distal = up to several hours after eating

What are the clinical signs of regurgitation?

• Appetite increased

• Weight loss or poor growth

What causes regurgitation?

• Megaesophagus

• Esophagitis

• Mechanical obstructions

• Endocrine disorders

• Neuropathies

• Immune mediated

What type of vascular anomalies cause regurgitation?

Persistent right aortic arch is most common

Can be subclavian artery

What are common findings in patients with regurgitation from vascular anomalies?

• Fibrous band encircling esophagus

• Dilation of esophagus before the heart

What is the treatment for vascular anomalies causing regurgitation?

Surgery to remove fibrous band (may cause long term esophageal problems)

Vomiting is a ________ sign of _______ disease

hallmark;

gastric

Vomiting is a _______ NOT a _________

clinical sign;

disease

Where does vomiting occur from if it’s centrally mediated?

• Vomit center in medulla oblongata - motor activity

• CTZ on floor of 4th ventricle - BBB less effective here

*Discharge of CTZ stimulates vomit center.

What activates receptors in the vomiting reflex?

Inflammation, irritation, distension, or hypersensitivity

What stimulates the vomiting reflex?

• Directly: certain blood borne drugs, toxins

• Indirectly: Afferent nerves or the CTZ

• Abdominal viscera: impulses along afferent nerve fibers in vagus & sympathetic nerves

What are the phases of vomiting?

• Nausea

• Retching (contraction of abdo mm.)

• Vomiting (+ pressure in thorax)

What is acute vomiting and who is it more common in?

• Less than 7 days

  • May be more severe vomiting

  • Consider dietary indiscretion, gastritis, obstruction of GI tract, viral diseases

• More common in younger dogs/cats

What is chronic vomiting and who is it more common in?

• More than once a day for more than 5 days or twice a week for more than 2 weeks

• More common in middle-aged to older animals because response takes time to develop

What are some complications of vomiting?

• Fluid loss or dehydration

• Electrolyte imbalance

  • Hypokalemia

  • Hypochloremia

  • Hyponatremia

• Acid-base changes

• Should NOT affect glucose

Graph for differentiating Dysphagia vs. Regurgitation

Graph for differentiating Regurgitation vs. Vomiting

Animals must maintain what in order to maintain proper function of their cells?

An aqueous environment

Aqueous and electrolyte components can be lost through what excretions?

Ocular, nasal, oral, urine, feces, sweat, and milk

What are evaporative losses?

The loss of water and electrolytes through the skin and respiratory tract, primarily due to sweating and breathing. This process is crucial for thermoregulation in animals

What 2 compartments do non-excretable body fluids exist in?

Intracellular and extracellular compartments

ECF can be subdivided into what?

Intravascular (IV-ECF) and extravascular/interstitial (EV-ECF)

What is the 3rd pool in which water exists in the body?

The transcellular fluid compartment

What charged particles are regulated in the ECF and the ICF?

ECF: Sodium, chloride, and albumin

ICF: Potassium and phosphate

Depleting the ________ pool of fluid may have a negative impact on the cardiovascular function and tissue perfusion WITHOUT actual dehydration

intravascular

Circle one: With severe enough changes in the ECF / ICF, electrolyte changes will also occur in the ECF / ICF

ECF; ICF

What mathematical equation has been a good estimator of ECF in adult and neonate LA? (Remember these are overestimates)

Adults: 0.3 x BW

Neonates: 0.5 x BW

What mathematical equation has been a good estimator of ECF in adult and neonate SA? (Remember these are overestimates)

Adults: 0.4 x BW

Neonates: 0.6 x BW

Most fluid plans can be divided into ____________ and ____________

Replacement and maintenance

Why are replacement fluids used?

To correct deficits, present in initial evaluation

Why are maintenance fluids used?

To keep the animal within certain homeostatic parameters for a longer period of time

When we determine a rationale for administration of fluids, we create a fluid therapy plan consisting of what 4 things?

1. Type of fluid

2. Rate of administration

3. Route of administration

4. Schedule and type of monitoring

What are Crystalloids?

Salts that are commonly used in fluid therapy to replace water and correct electrolyte and acid-base disturbances (e.g., Norm-R, LRS, Normal Saline)

What are Colloids?

Plasma, protein, or synthetic substances used in fluid therapy to replace lost protein, supply deficient immunoglobulin, or increase IV-ECF oncotic pressure

Blood or blood replacers have the same benefit as _______ and increase the oxygen carrying capacity of blood

Colloids

Lipid, glucose, and amino acids in fluids used to what?

Provide energy

What is the general rule for a shock dose?

Up to a blood volume may be given over 20 minutes. Shock doses may be repeated if there is insufficient response, especially when a partial dose is given

How is dehydration assess for the non-shocky patient?

Usually based on % body weight lost but pre-dehydration weight not always available or reliable. Clinically, use data: BUN and Creat, PCV, TP, Lactate

Dehydration table

For replacement, the calculated percentage of body weight is usually given over ________

2-4 hrs

What does Goal-directed fluid therapy look for?

Changes in specific parameters such as central venous pressure, urine output, or blood lactate to judge sufficiency of fluid replacement

The amount of maintenance fluids administered should roughly equate what?

The amount used or lost over the same period of time

Chart for maintenance fluids

What are the 5 routes of fluids administeration?

1. Oral

2. Subcutaneous

3. Intravenous

4. Intraosseous

5. Intraperitoneal

What parameters should be monitored to prevent overhydration, overtreatment, and justify sufficiency of current plan?

1. Body weight

2. Physical determinants: HR, NN, skin turgor, eye luster

3. Central Venous Pressure

4. PCV/TP

5. Urine volume

6. Evidence of pulmonary, cerebral, or peripheral edema