Clinical approach to vomiting and diarrhea in the dog and cat (Proceedings)

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.