Approach to Vomiting



-Primary GI

?Gastric

?Small intestinal

?Colonic

-Secondary GI

?Systemic illness that affects GI function

Secondary GI Causes of Vomiting

SYSTEM

-Kidneys

-Liver

-Exocrine pancreas

-Endocrine pancreas

-Adrenals

-Peritoneum

-CNS

-Thyroid

-Uterus

-Systemic infection

Disease:

-Renal failure

-Hepatic disease

-Pancreatitis

-DKA

-Addison's

-Peritonitis

-Cerebral or vestibular disease

-Hyperthyroidism

-Pyometra

-Sepsis

Overview:

Gastric Causes of Chronic Vomiting

-Chronic gastritis

?Lymphocytic/plasmacytic

?Eosinophilic

?Associated with GHLOs

?Parasitic

?Reflux gastritis

-Gastric foreign body

-Gastric ulceration

-Gastric motility disorders

-Gastric neoplasia

Overview:

Intestinal Causes of Chronic Vomiting

-Inflammatory bowel disease (IBD)

-Intestinal neoplasia

-Duodenal ulcers

-Fungal enteritis

-Chronic intussusception

-Foreign bodies

-Colitis

Chronic Vomiting: History

-Characterize vomiting

?Onset

?Duration

?Frequency

?Progression

?Relationship to eating

?Specific features (blood, foreign material, undigested food, projectile, etc.)

?Response to changes in diet or feeding schedule, medication, other changes

Associated clinical signs-

?Appetite changes

?Weight loss

?Diarrhea

?Changes in attitude (lethargy)

?PU/PD

?Cough, tachypnea, dyspnea

?Other

-Potential exposures prior to onset:

?Medications

?Plants

?Toxins

?Garbage

?Potential foreign bodies

?Other sick animals

-Dietary history

-Deworming history

-Vaccination status

-Past medical history

-Past surgical history

Approach to Vomiting:

-Primary GI

?Gastric

?Small intestinal

?Colonic

-Secondary GI

?Systemic illness that affects GI function

Chronic Vomiting:

Diagnostic Steps

-CBC, biochemistry profile, UA

-Fecal

-Survey abdominal radiographs

-Cats:

?T4 if over 6 yrs, FeLV, FIV

?occult heartworm test

-Elimination diet

-Endoscopy

-Abdominal ultrasound

-Barium series

-Laparatomy

Approach to Chronic Vomiting

CBC, biochemistry profile, UA, fecal

Survey abdominal radiographs

Cats: T4 if over 6 yrs, FeLV, FIV (occult heartworm test)

Mild Signs:

-Elimination diet

Significant Clinical Signs:

-Endoscopy

-Abdominal ultrasound

-Barium series

-Laparotomy

Overview:

Gastric Causes of Chronic Vomiting

-Chronic gastritis

?Lymphocytic/plasmacytic

?Eosinophilic

?Associated with GHLOs

?Parasitic

?Reflux gastritis

-Gastric foreign body

-Gastric ulceration

-Gastric motility disorders

-Gastric neoplasia

Chronic Gastritis

Classified by etiology, breed, and/or histopathology

Types of Chronic Gastritis

?Lymphocytic/plasmacytic gastritis (Chronic non-specific gastritis, IBD)

?Eosinophilic gastritis

?Granulomatous gastritis

?Atrophic gastritis

?Gastritis associated with GHLOs

?Parasitic gastritis

?Reflux gastritis

Etiopathogenesis of Chronic Lymphocytic/Plasmacytic Gastritis

-Non-specific reaction to many insults

-Either wall defects allow antigen absorption from stomach stimulating immune response OR breakdown in immune tolerance (auto-immune gastritis)

-Mucosal damage allows back-diffusion of acid

-Gastric inflammation compromises motility, secretions and plasma proteins lost into lumen

Chronic Lymphocytic/Plasmacytic Gastritis: Clinical Features

-Persistent intermittent vomiting exacerbated by eating

-Diarrhea occurs if animal has concurrent IBD of intestines

-PE, CBC, chemistries, UA, fecal, and survey radiographs ? typically NAF

Chronic Lymphocytic/Plasmacytic Gastritis: Diagnosis

-Obtain endoscopic biopsies or full-thickness biopsies by laparotomy

-Infiltration of the gastric mucosa predominantly with lymphocytes and plasma cells

-Mucosa may be normal thickness (simple gastritis), increased (hypertrophic), or decreased (atrophic)

Note: Mucosal hypertrophy can cause outflow obstruction

Chronic Lymphocytic/Plasmacytic Gastritis: Treatment

PRIMARY THERAPY

-+/- NPO or ?no food? for 24-48 hours

-Multiple small daily meals

?Easily digested diet (i/d)

?Novel protein diet (e.g. venison and rice)

?Hydrolyzed protein diet (z/d, HA)

-Gastric protectant (Sucralfate)

-Treat for ulceration if indicated

SECONDARY THERAPY

-Prednisolone 1-2 mg/kg PO q12 hr, tapered

-Usually reserve antiemetics for acute exacerbations

Eosinophilic Gastritis

-Clinical signs like L/P gastritis

-Inflammatory infiltrate dominated by eosinophils

-May have peripheral eosinophilia

-May be associated with:

?Generalized eosinophilic gastroenteritis (dogs and cats)

?Eosinophilic granulomas (dogs)

?Hypereosinophilic syndrome (cats)

Eosinophilic Gastritis

-Suspected etiologies

?Parasites

?Dietary hypersensitivity

?Hypereosinophilic syndrome (cats) ? neoplastic-

Eosinophilic Gastritis: Treatment

-Therapeutic deworming

-Treat as for L/P gastritis except use prednisolone as part of primary therapy

-Cats usually require higher doses of steroids for control (2-3 mg/kg q12 hr)

-If refractory, add azathioprine

-Resect granulomatous masses

Eosinophilic Gastritis: Prognosis

-Eosinophilic gastritis +/- enteritis: Good prognosis for control of clinical signs

-Hypereosinophilic syndrome in cats: Very guarded prognosis