3 General Therapeutic Principles for GI Disorders

66%

How much fluid of the body is intracellular?

33%

How much of the fluid in the body is extracellular?

Interstitial fluid = 75% of the 33

Intravascular fluid = 25% of the 33

33% of the body's fluid is extracellular. What are the two categories of extracellular fluid, and how much is each?

INTERSTITIAL: this is the network around the cell itself where lots of nutrient exchange happens. so, when this is depleted, this is where signs of the dehydration come from (slow skin tent, sunken orbits)

INTRAVASCUALR: fluid deficit here causes hypovolemia (weak femoral pulses, tachycardia)

Interstitial fluid and intravascular fluid make up extracellular fluid. What is the difference between these, in terms of what happens when they are depleted?

balanced isotonic fluids like LRS/Plasmalyte-A

Which corrects acid-base deficiencies faster: acidifying fluids like 0.9% NaCl OR balanced isotonic fluids like LRS/Plasmalyte-A

Hypoalbuminemia

What is a common protein that is deficient as a result of chronic GIT disease?

Fresh frozen plasma (blood products), synthetic colloids (hetestarch aka HES)

Name some sources that can provide oncotic support in terms of fluid therapy

note: something that supplies oncotic support means it supplies albumin and other proteins that increase intravascular colloid pressure

Enteral (PO)

What is the BEST route for the GIT in terms of fluids, if the patient can tolerate it?

Parenteral (IV, IO)

Which route of fluid administration is indicated in hypovolemic/dehydrated patients or in one that cannot tolerate enteral fluids?

In MILD dehydration cases or giving maintenance fluids up to 20-30 mL/kg

What is the ONLY case which you should be using SQ fluids?

12-24 hours

Ideally, within WHAT TIMELINE are you correcting fluid deficits and electrolyte imbalances in patients?

10-20 mL/kg/SITE

For small animals, you administer SQ fluids according to 20-30 mL/kg. What is the max you can do PER SITE?

Dehydration status, maintenance, and ongoing losses

Fluids are considered a prescription and must be changed for each patient. So, for fluids like daily crystalloids, what things are you taking into account?

5-6% = MILD: minimal loss skin turgor, semidry MM

7-8% = MODERATE: moderate loss skin turgor, dry MM, weak rapid pulse

9-10% = SEVERE: marked loss skin turgor, dry MM, weak pulses, hypotension, sunken eyes, tachycardia

Less than 5% dehydration is considered euhydrated. Tell me the other 3 stages of dehydration, and what you would expect to see at each.

Fluid deficit in L = BW (kg) x % dehydration

SO, 35 kg x 0.07 = 2.45 L WHICH IS 2,450 mL deficit

Sally is a 35 kg, 5 year old, female spayed lab who presents for vomiting, diarrhea, and anorexia of 24 hour duration. She is approximately 7% dehydrated after having gotten into the garbage. What's her dehydration deficit?

Maintenance needs 60 mL/kg/day for DOGS.

SO, 35 kg x 60 mL/kg = 2,100 mLs/day

Sally is a 35 kg, 5 year old, female spayed lab who presents for vomiting, diarrhea, and anorexia of 24 hour duration. She is approximately 7% dehydrated after having gotten into the garbage. What are Sally's maintenance needs for fluids?

DOGS = 60 mL/kg/day

CAT = 40 mL/kg/day

What are the maintenance needs for dogs and cats in terms of fluid?

1 cup of vomit/diarrhea = ABOUT 240 mLs

SO, just double this because she has vomit/diarrhead 2 cups = 480 mLs of ongoing fluid loss

Sally is a 35 kg, 5 year old, female spayed lab who presents for vomiting, diarrhea, and anorexia of 24 hour duration. She is approximately 7% dehydrated after having gotten into the garbage. What are Sally's ongoing losses if she's lost about 2 cups of vomit/diarrhea in the last hour?

ADD ALL LOSSES: 480 mL + 2,100 mL + 2,450 mL

= 5,030 mL/24 hours

= 210 mL/1 hour

RESUSCITATION BOLUS = (range is 15-20 for dogs, but lets go with the lower number)

15 mL/kg x 35 kg = 525 mL resuscitation bolus over 15-20 minutes

This means we have to take 525 mL out of our TOTAL, which was 5,030 mL in 24 hours.

This changes our 24 hour total to 4,505 mL/24 hours

Which consequently lowers our hourly rate to 188 mL/1 hour

Sally is a 35 kg, 5 year old, female spayed lab who presents for vomiting, diarrhea, and anorexia of 24 hour duration. She is approximately 7% dehydrated after having gotten into the garbage.

We have determined 480 mLs of ongoing fluid loss, 2,100 mL/day needed for maintenance, and a 2,450 dehydration deficit.

How many fluids does this mean she needs in 24 hours AND how many does she need in 1 hour? If we give a resuscitation bolus for this dog, how much fluid does this mean she gets over 15-20 minutes initially, and what does this change

15-20 mL/kg DOGS over 15-20 mins

5-10 mL/kg CATS over 15-20 mins

For animals that have severe fluid deficits, we give resuscitation fluid boluses to get fluid onboard faster. How much fluid is this for dogs and cats over 15-20 minutes?

Do NOT GIVE more than 0.5 mmol/kg/hr of KCl

You should add KCl to your fluids at some point for small animal patients. What is the MAX AMOUNT you can give of this?

Do NOT give your patients more than 10% of their body weight in fluid

You want to give fluids to help rehydrate your patient. But, too much fluid can hurt them. How much fluid is TOO MUCH, where you are getting to fluid overload territory?

Furosemide

You have accidentally given your patient WAY too much fluid. What drug can help you correct this?

In patients with normal vascular permeability, only 25% of the IV isotonic crystalloids you administered remain in the intravascular space after 30 minutes, the rest has moved to the interstitial space. This is why you should consider colloids like hetestarch when treating for hypovolemia

In patients with normal vascular permeability, only 25% of the IV isotonic crystalloids you administered remain in the interstitial/intravascular space after 30 minutes, the rest has moved to the other space. This is why you should consider colloids like hetestarch when treating for hypovolemia

Hypovolemic cats show: hypotension, hypothermia, and bradycardia

note: this is different from dogs, who show tachycardia

What is the classic hypovolemic cat "triad" of signs?

LOW FAT: weight loss, chronic pancreatitis

ULTRA LOW FAT: protein losing enteropathy

When would it be appropriate to use low fat and ULTRA low fat diets in dogs?

Large

Fiber is often useful in the management of large or small intestinal diarrhea

INSOLUBLE

Which increases fecal bulk, which stimulates motility and decreases spasms in dogs with large intestinal diarrhea, soluble or insoluble fibers

RER (basal) = 30 x BW in kgs + 70 = kcal/day

DER = RER x lifetime factor = kcal/day

How do you calculate RER and DER (same as MER)?

RER (basal) = 30 x BW in kgs + 70

SO = (30 x 10) + 70 = 370 kcal/day RER

DER = RER x 1.5

SO, 370 kcal/day x 1.5 = 555 kcal/day DER

Jack is a 1 year old intact MinPin that weighs 10 kgs who is recovering from his injuries after being hit by a car. How many kcal/day does he need?

note: the lifetime factor is 1.5

a. mirtazapine

b. cyproheptadine

d. capromorelin (elura) = which is FDA approved for cats with chronic kidney disease and weight loss

All of the following are appetite stimulants. Select which of the following may be used in cats:

a. mirtazapine

b. cyproheptadine

c. capromorelin (entyce)

d. capromorelin (elura)

a. mirtazapine

c. capromorelin (entyce) = which is FDA approved for appetite stimulation in dogs

All of the following are appetite stimulants. Select which of the following may be used in dogs:

a. mirtazapine

b. cyproheptadine

c. capromorelin (entyce)

d. capromorelin (elura)

c. pharyngostomy

Which is NOT a method of tube feeding which can be used:

a. orogastric

b. nasogastric/esophageal

c. pharyngostomy

d. esophagostomy

e. gastrostomy

f. enterostomy

esophagostomy

Which is better for longer term tube feeding, using gruel instead of requiring liquid formula: esophagostomy or nasogastric

TPN = total parenteral nutrition = IV solution administered thru dedicated jug. IV catheter

PPN = partial parenteral nutrition = provides 50% of caloric requirement thru peripheral catheter

What is the difference between TPN and PPN?

RISK OF INFECTION

What is the MAJOR disadvantage of using total or partial parenteral nutrition for animals?

a. cerenia/maropitant

Which centrally acting antiemetic is an NK-1 antagonist:

a. cerenia/maropitant

b. ondansetron/zofran

c. metoclopramide/reglan

b. ondansetron/zofran

Which centrally acting antiemetic is a 5-HT antagonist:

a. cerenia/maropitant

b. ondansetron/zofran

c. metoclopramide/reglan

c. metoclopramide/reglan

Which centrally acting antiemetic is a CRTZ inhibitor and prokinetic:

a. cerenia/maropitant

b. ondansetron/zofran

c. metoclopramide/reglan

1. acid titrating drugs

2. gastric acid secretion inhibitors (H2 blockers)

3. proton pump inhibitors (PPIs)

Name the 3 MAJOR categories of antacids to lower gastric acid levels?

Proton pump inhibitors

There are 3 major categories of antacids:

1. acid titrating drugs

2. gastric acid secretion inhibitors (H2 blockers)

3. proton pump inhibitors (PPIs)

WHICH ONE OF THESE is the MOST effective for gastric ulceration and esophagitis?

b. aluminum/magnesium hydroxide

Select which of the following antacids are acid titrating drugs:

a. cimetidine

b. aluminum/magnesium hydroxide

c. ranitidine

d. famotidine

e. omeprazole

f. iansoprazole

a. cimetidine

c. ranitidine

d. famotidine

Select which of the following antacids are H2 blockers, which upregulate receptors so that acid "escapes" thru long term use:

a. cimetidine

b. aluminum/magnesium hydroxide

c. ranitidine

d. famotidine

e. omeprazole

f. iansoprazole

b. ranitidine

c. nizatidine

Select which of the following H2 antacids HAVE prokinetic properties:

a. cimetidine

b. ranitidine

c. nizatidine

d. famotidine

e. omeprazole

f. iansoprazole

Select which of the following antacids are proton pump inhibitors, the MOST EFFECTIVE ANTACIDS:

a. cimetidine

b. aluminum/magnesium hydroxide

c. ranitidine

d. famotidine

e. omeprazole

f. iansoprazole

Intestinal protectants

What is the BROAD purpose of Sucralfate and Misoprostol?

Treat exocrine pancreatic insufficiency

What is the point of Viokase-V?

Treat diarrhea by delaying transit time in the GIT

What is diphenoxylate and loperamide used to do?

Careful using in MDR gene mutation breeds like collies

Diphenoxylate and loperamide are both used to treat diarrhea in dogs. BUT you have to be careful about using these medications in WHAT ANIMALS?

Stomach and proximal duodenum

Metoclopramide is a prokinetic agent on WHICH PARTS of the GIT?

Cisapride

What is the 5 HT agonist that stimulates motility from the lower esophageal sphincter to the anus?

Corticosteroids

What is the primary anti-inflammatory drug for moderate to marked inflammatory bowel disease treatment?

Helicobacter gastritis

Combination of amoxicillin, metronidazole, and bismuth are used for symptomatic treatment of WHAT problem in animals?

Tylosin

SEVERE antibiotic responsive enteritis can be treated with metronidazole and enrofloxacin combo

What medication is commonly use to treat antibiotic responsive enteritis and clostridial colitis in animals?

Probiotic

This means the drug is a live bacterial or yeast supplement

Prebiotic

This means the drug is a specific dietary substance (fiber) that increases or influences the number of specific bacteria in the gut

Fortiflora, Prostora, Proviable

Name some veterinary prebiotics/probiotics

Hypertonic

Which type of enema should NOT BE USED

Lactulose

This is an osmotic laxative to soften stool, but can cause severe osmotic diarrhea so it must be titrated to effect

a. fenbendazole (panacur)

c. Pyrantel

d. Drontal (pyrantel/febantel/praziquntel)

e. Ivermectin/Pyrantel (Heartgard +)

f. Milbemycin (sentinel)

Select the drugs which can be used to treat hookworms:

a. fenbendazole (panacur)

b. metronidazole (flagyl)

c. Pyrantel

d. Drontal (pyrantel/febantel/praziquntel)

e. Ivermectin/Pyrantel (Heartgard +)

f. Milbemycin (sentinel)

a. fenbendazole (panacur)

c. Pyrantel

d. Drontal (pyrantel/febantel/praziquntel)

e. Ivermectin/Pyrantel (Heartgard +)

f. Milbemycin (sentinel)

Select the drugs which can be used to treat roundworms:

a. fenbendazole (panacur)

b. metronidazole (flagyl)

c. Pyrantel

d. Drontal (pyrantel/febantel/praziquntel)

e. Ivermectin/Pyrantel (Heartgard +)

f. Milbemycin (sentinel)

d. Drontal (pyrantel/febantel/praziquntel)

f. Praziquantel

Select the drugs which can be used to treat tapeworms:

a. fenbendazole (panacur)

b. metronidazole (flagyl)

c. Pyrantel

d. Drontal (pyrantel/febantel/praziquntel)

e. Ivermectin/Pyrantel (Heartgard +)

f. Praziquantel

a. fenbendazole (panacur)

d. Drontal (pyrantel/febantel/praziquntel)

e. Imidocloprid/moxidectin (Advantage multi)

f. Milbemycin (sentinel)

Select the drugs which can be used to treat whipworms:

a. fenbendazole (panacur)

b. metronidazole (flagyl)

c. Pyrantel

d. Drontal (pyrantel/febantel/praziquntel)

e. Imidocloprid/moxidectin (Advantage multi)

f. Milbemycin (sentinel)

c. Trimethoprim-sulfadiazine

f. Sulfadimethoxine

Select the drugs which can be used to treat coccidia:

a. fenbendazole (panacur)

b. metronidazole (flagyl)

c. Trimethoprim-sulfadiazine

d. Drontal (pyrantel/febantel/praziquntel)

e. Imidocloprid/moxidectin (Advantage multi)

f. Sulfadimethoxine

a. fenbendazole (panacur)

b. metronidazole (flagyl)

Select the drugs which can be used to treat giardia:

a. fenbendazole (panacur)

b. metronidazole (flagyl)

c. Trimethoprim-sulfadiazine

d. Drontal (pyrantel/febantel/praziquntel)

e. Imidocloprid/moxidectin (Advantage multi)

f. Sulfadimethoxine