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Clinical approach to vomiting and diarrhea in the dog and cat (Proceedings)
Diagnosing and treating acute and chronic causes of vomiting and diarrhea.
History
• Signalment
o Age
o Breed
• Previous Medical History
• Current Medical History
• Physical Examination!!
Causes of Vomition
• Activation of Vomition Center:
o Peripheral sensory receptors (afferents)
o Chemoreceptor trigger zone (area postrema)
o Vestibular afferents ("motion sickness")
o Psychogenic ("higher centers")
• Intestinal inflammation
• Heartworms — cats
Acute Vomiting (< 3 days)
• Young Dogs & Cats (< 6 months)
o Dietary
o Intestinal Parasites
o Systemic Diseases
■ Viral
■ Bacterial
■ Fungal
o Intussusception
o Foreign Body
o Toxins
Minimum Data Base — Acute Vomiting
• History
• Physical Examination
• Fecal flotation
• Abdominal Radiographs
• ± CBC (systemic signs!)
• ± Chemistry panel (systemic signs!)
• ± Urinalysis (systemic signs!)
Chronic Vomiting (> 3 Days)
• Young Dogs & Cats (< 6 months)
o Dietary
o Intestinal Parasites
o Systemic Diseases
■ Bacterial
■ Fungal
o Intussusception
o Foreign Body
Minimum Data Base — Chronic Vomiting
• History (past and present)
• Physical Examination
• Fecal flotation
• Abdominal Radiographs
• CBC
• Chemistry panel (electrolytes!)
• Urinalysis
• ± Blood gases
Vomition
Specific Diagnostic Procedures
• Contrast radiography – Barium series for filling defects, mucosal or mural lesion and transit (emptying).
• Ultrasonography — mural masses & thickening, possible guided biopsies.
• Endoscopy — gastric foreign body, ulcerations, masses, mucosal biopsies for histologic examination.
• Exploratory laparotomy – gastrotomy, biopsies or resection for histologic examination
Treatment for Vomiting
• Supportive:
o Nothing per os (NPO)
o Correct fluid deficits
■ SQ, IV fluids
o Correct electrolyte and acid-base abnormalities
• Symptomatic – anti-emetics:
o Vomition center & chemoreceptor trigger zone — phenothiazines
o Chemoreceptor trigger zone & vestibular apparatus — antihistamines
o Dopaminergic antagonists – metaclopramide
o Serotonin antagonists – ondansetron,dolansetron
o Neurokinin receptor antagonist – maropitant citrate
o Anticholinergics ("antispasmotics") – AVOID!! often will cause or exacerbate ileus and vomition !
• Specific — depends on diagnosis:
o Surgical
o Medical:
■ Dietary
■ H2 receptor antagonist — ranitidine & famotidine
■ Motility modifiers — metoclopramide
■ Protectant — sucralfate
■ Antibiotics — parenteral
■ Anti-inflammatory or Immunosuppressives — corticosteroids
Causes of Diarrhea
• Osmotic — water-soluble materials that are not assimilated (retains water)
• Secretory — stimulation of glands
• Exudative — increased permeability or hydrostatic pressures and hemorrhage
• Motility derangement — hypomotility >> than hypermotility !
• Mixed causes most common !!
Clinical Signs
• Small Bowel :
o Watery
o Increased volume !
o Frequency normal to increased
o Vomiting
o Steatorrhea
o Melena
o Weight loss
o Anorexia/polydypsia
o Ascites
o Anemia
Protein Losing Enteropathies
• Intestinal:
o Acute enteritis:
■ Infectious — Parvo virus, salmon poisoning, Salmonella, etc.
■ Hemorrhagic Gastroentetitis (HGE)
o Parasitism — Ancylostoma, Trichuris, etc.
o Chronic enteritis:
■ Inflammatory — lymphocytic-plasmacytic, eosinophilic, etc.
■ Infiltrative —Histoplasmosis, Prototheca, etc.
■ Ulcerative — neoplasia, cecal eversion, granulomatous, etc.
■ Lymphatic derangement — lymphangiectasia
■ Congestive heart failure — right-sided
Other Clinical Signs
• Systemic disease:
o Fever !
o Lymphadenopathy !
Acute Diarrhea
• History—dietary changes or "indiscretions"
• Physical examination
• Fecal — character and floatation
• CBC (for severe diarrhea)
• Chemistry panel (for severe diarrhea)
• Urinalysis (for severe diarrhea)
• ± Abdominal radiographs
• ± Abdominal ultrasound
Minimum Data Base - Chronic Diarrhea
Extensive work-up is required !
• History, Physical & Fecal examinations
• CBC, Chemistry panel & Urinalysis
• Abdominal radiographs/ultrasound
• Specific tests — TLI/PLI, B12, Folate, fecal cytology,culture, serology (?), endocrine function tests, etc.
• Endoscopy & biopsy — histopathology
• Exploratory laparotomy & biopsy — histopathology
Diarrhea Specific Diagnostic Procedures
• Ultrasonography — mural masses & thickening, possible guided biopsies
• Endoscopy — gastric foreign body, ulcerations, masses, and mucosal biopsies for histologic examination (upper GI and colonoscopy)
• Exploratory laparotomy — enterotomy, biopsies or resection for histologic examination
• Treatment for Diarrhea
• Supportive:
o Rest GI tract — "NPO" or ice cubes only (may be all that is required in acute diarrhea)
o Fluid & Electrolytes — isotonic & KCL added
o Parenteral (hyper)alimentation — central IV catheter & dedicated line (strict asepsis)
■ Caloric requirement
■ Protein requirement
o Slow reintroduction of food
Treatment of Diarrhea
• Symptomatic:
o Motility modifiers —
■ Narcotic analgesics !
■ Anticholinergics ? – AVOID!! diarrhea's are usually due to hypomotility!
o Absorbents & Protectants — Bismuth, Kaolin, etc.
o Dietary — increase or decrease fiber, decrease fat
• Specific:
o Dietary:
■ easily digested, fat-free , gluten free, novel protein source (may be all that is required in dietary induced diarrhea)
■ Then balanced diet — make changes slowly!
o Antimicrobials – parenteral
o Anthelmentics!!! — fenbendazole
o Immunosuppresive / Anti-inflammatory — metronidazole, corticosteroids, azothioprine, sulfasalazine
o Surgical — bowel resections, etc.
