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

August 1, 2008
Susan Eddlestone, DVM, DACVIM

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

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■ 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.

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