SA V+

History

·    How long been going on for? – acute vs chronic

·    Are they a scavenger? Access to any toxins?

·    Any recent diet changes?

·    Any other animals in house affected? – if yes = infectious causes

·    Nature of vomit – amount, colour, frequency?

·    Any diarrhoea? – suggests intestinal cause

·    Previous abdominal surgery? History of oesophagitis?

·    Vaccination and worming status?

·    Any gagging/retching/coughing? – want to differentiate from regurgitation

Clinical examination

·    Hydration status

·    BCS – differentiate acute vs chronic (BCS loss)

·    MM colour – anaemic? Jaundiced?

·    Check under tongue – linear FB?

·    Abdominal palpation – any pain, thickening, effusion, palpable FB, organomegaly

·    Abdominal auscultation – ileus, borborygmi

·    Rectal examination – mass, FB, temperature

·    Neurological exam – is vomiting/vestibular system affected?

·    Any signs of systemic disease, e.g. pyrexia, PUPD, jaundice

Further investigations

·    Want to rule out obstruction – risk of acute death/sepsis (GIT can burst due to increased pressure, necrosis due to decreased blood supply)

·    Blood sample

o  Haematology – assess hydration status, infectious diseases

o  Biochemistry – look at liver/renal parameters, investigate metabolic disease

·    Abdominal radiography – FB, masses, distended SI

·    Abdominal U/S – loss of serosa, free fluid, intestinal wall thickness, neoplasia, intussusception

·    Specific tests once more localised cause

o  Faecal analysis

o  FeLV/FIV snap test

o  Total T4, ACTH, cPLI

Management

·    Don’t want to give anti-emetics straight away as vomiting may be beneficial

o  But if >12h AND RULED OUT FB – give anti-emetic (will feel better, encourage eating)

§ Maropitant – good for metabolic, CRTZ, vestibular

§ Metoclopramide – also prokinetic, if FB could rupture GIT

·    Supportive – GI diet (feeding tube if still not eating), gastroprotectant (omeprazole), prokinetics if D+, IVFT to replace ongoing losses

·    Treat underlying cause, e.g. treat metabolic disease, surgical removal of obstruction

Regurgitation

·    Passive expulsion of food – undigested, soon after eating

·    Treatment:

o  Maintain hydration/replace losses with IVFT

o  Trial different food types

o  Treat underlying cause:

§ Megaoesophagus – no treatment, just feed small amounts from height

§ Oesophagitis – PEG tube to bypass

§ Oesophageal FB – surgical removal

Acute vomiting

·    GI tract

o  Obstructive – FB, neoplasia, parasitic, constipation, intussusception/volvulus

o  Inflammatory – gastritis, gastroenteritis, colitis

o  Mucosal insult – dietary indiscretion/intolerance, sudden diet change, toxins

o  Infectious – viral, bacterial, parasitic

o  Gastric stretch

·    Cerebral cortex – increased ICP, head trauma

·    Vestibular system – motion sickness, idiopathic vestibular disease, otitis interna

·    CRTZ

o  Endogenous – DKA, Addison’s, AKI, pancreatitis, pyometra, hepatitis, peritonitis

o  Exogenous – toxins, drugs (e.g. NSAIDs causing ulcers)

Chronic vomiting

·    GI tract

o  Chronic inflammatory – gastritis, gastroenteritis, colitis, chronic enteropathy

o  Mucosal insult – dietary intolerance

o  Infectious – viral, bacterial, parasitic

o  Obstructive – pyloric FB, neoplasia, parasitic, constipation

·    Cerebral cortex – neoplasia/SOL, CNS disease

·    Vestibular system – chronic vestibular damage, otitis interna, neoplasia, cerebellar disease

·    CRTZ

o  Endogenous – diabetes mellitus, Addison’s, chronic renal failure, liver failure, chronic pancreatitis, hyperthyroidism (cats)

Regurgitation

·    Dilation – megaoesophagus

·    Obstruction

o  Intraluminal – FB, stricture (secondary to oesophagitis, post GA)

o  Mural – neoplasia, inflammation

o  Extramural – vascular ring anomaly, hiatal hernial, neoplasia/SOL

·    NM disorders – myasthenia gravis, botulism, tetanus, distemper, Addison’s, hypothyroidism

Dysphagia

·    Pain on closing mouth (dental disease, stomatitis), opening mouth (retrobulbar abscess) or both (jaw fracture, TMJ disease)

·    Failure of NM control – CN disease, CNS disease, masticatory myositis, botulism, myasthenia gravis

·    Obstruction, e.g. pharyngeal FB, poly, neoplasia, abscess, lymphadenopathy

GI neoplasia’s

·    Most common:

o  Adenocarcinoma (most common in dogs)

§ If gastric – see haematemesis (coffee granules)

§ If SI/colonic – see ribbon-like faeces

o  Leimyosarcoma

o  Lymphoma (most common in cats)

o  Polyps

·    Diagnosis: full thickness biopsy, mets check

·    Treatment: surgical excision +/- draining LNs

History

·    How long been going on for?

·    Up to date with vaccinations and worming protocols? Any medications?

·    Are they a scavenger? Access to toxins? What diet are they on? Any recent changes?

·    Nature of diarrhoea? Appearance? Frequency? – yellow + fatty = EPI, blood = LI, incr. frequency = LI, increased volume = SI

·    Are they straining? – tenesmus = LI

·    Any vomiting? Are they still eating

·    Any other clinical signs? – pruritus = food responsive enteropathy

·    Any other animals in house affected?

·    Previous abdominal surgery?

·    Want to differentiate between SI and LI

o  SI = weight loss, watery/bulky faeces, increased volume, 1-3x daily, no tenesmus, no mucus, no melena

o  LI = no weight loss, appearance varies, normal/decreased volume, >6x a day, tenesmus, mucus, fresh blood present

·    Age of animal? – young puppy or old unvaccinated dog = parvo

Clinical examination

·    Hydration status

·    BCS/weight loss? – differentiate acute vs chronic, weight loss = chronic SI

·    Abdominal palpation – any pain/discomfort? Thickened intestines, palpable FB

·    Abdominal auscultation – ileus, borborygmi

·    Rectal examination – temperature, mass, FB, blood

·    Cardiac abnormalities – addisons, cardiac disease

·    Signs of systemic disease, e.g. pyrexia

·    Palpable thyroid

·    Examine skin – poor coat = food sensitivity

Further investigations

·    Blood sample for haematology

o  Anaemia – chronic disease, GI bleeding

o  PCV – increased = dehydration

o  Inflammatory leukogram – inflammation, infection, parasites

o  Lymphopenia – lymphangiectasia

o  Eosinophilia – parasites, hypoadrenocorticism

o  Lymphocytosis – neoplasia, hypoadrenocorticism

·    Blood sample for biochemistry – looking for markers of systemic disease

o  Total proteins – increased = dehydration

o  Albumin + globulin – decreased = PLE, high globulin = FIP

o  Azotaemia (high urea + creatinine) – dehydration

§ High urea + low protein – GI bleeding

§ Low urea + low cholesterol, albumin + glucose = functional liver disease

o  Electrolytes – abnormalities = fluid imbalance, high K + low Na = hypoadrenocorticism

o  Liver enzymes – increased ALT = EPI

o  Cholesterol – low cholesterol = malabsorption, functional liver disease

·    TLI if suspect EPI – will be decreased

·    Urinalysis – USG – marker of hydration status and renal disease

·    Faecal analysis

o  Culture – campylobacter, salmonella, E. coli

o  Faecal parasitology – giardia

o  Faecal virus tests – SNAP test = parvo, PCR = campylobacter, parvo

·    Imaging – U/S, radiography, endoscopy – thickened intestinal wall = steroid responsive enteropathy, look for tumour

Management

·    General symptomatic treatment:

o  IVFT to restore losses, tx dehydration – Hartmann’s (has buffering capacity)

o  Bulking agents: peridale 98% - increases bulk of intestinal contents, promotes peristalsis

o  Prebiotic: lactulose, probiotics

o  Prokinetics: metoclopramide – for chronic D+, reduces ileus, promotes motility

o  Antibiotics – if evidence of sepsis, or based on C+S

·    Parvovirus – aggressive IVFT, amoxicillin, maropitant, metoclopramide

·    Campylobacter – fluroquinolones

·    Food responsive enteropathy – diet trial to rule out, should see GI improvements in 1w

·    Steroid responsive enteropathy – dietary support