Approach to Disorders of the Gastrointestinal Tract 2024 PDF

APPROACH TO… DISORDERS OF THE GASTROINTESTINAL TRACT PRIYA SHARP LEARNING OBJECTIVES Understand how to restrain and perform a comprehensive clinical examination including history-taking and physical examination and identify the key clinical problems and the body systems...

APPROACH TO… DISORDERS OF THE GASTROINTESTINAL TRACT PRIYA SHARP LEARNING OBJECTIVES Understand how to restrain and perform a comprehensive clinical examination including history-taking and physical examination and identify the key clinical problems and the body systems involved. Demonstrate a rational, evidence-based, problem-solving approach to the common presentations in companion animal practice. Perform clinical reasoning, involving structuring an appropriate differential diagnoses list and recommending appropriate further investigations. Understand how to take appropriate samples and request appropriate tests. Interpret and appraise laboratory reports and clinical data as part of management of a clinical case. Formulate appropriate treatment, patient care, control, and prevention plans including euthanasia. Understand how to critically review and evaluate evidence, in support of practising evidence based veterinary medicine. 2 REFRESHER The gastrointestinal tract (GIT) consists of the following Oral cavity Oropharynx Oesophagus Stomach Small intestine Large intestines Rectum Anus (Liver and Pancreas) Msdmanual.com Considerations Clinical signs (problem list) Disorders (differential list) Investigation (diagnostics) 3 GASTROINTESTINAL DISEASE Very common Most self-limiting Those requiring further investigation/treatment must be identified Failure to respond to symptomatic treatment Seriously ill at presentation Clinical signs Not just vomiting and diarrhoea Vomiting and diarrhoea may not be caused by primary GIT disease Thorough history Not always as reported (vomiting vs regurgitation vs dysphagia) Careful and complete physical examination Some if not most of the GIT is not easy to physically examine Excellent client communication 4 APPROACHING A CASE If non-life threatening/in need of immediate treatment History Resolution Symptomatic Problem List treatment Physical Non Exam Resolution 5 APPROACHING A CASE – PROBLEM BASED APPROACH Life threatening/in need of immediate treatment History Problem List Differential Diagnostic Treatment Systemic Disease Diagnosis Multiple (Concurrent) Investigation Disease Physical Exam 6 ANOREXIA Loss or lack of appetite not eating? not wanting to eat? not able to eat?? Partial (hyporexia) or complete True anorexia: decreased appetite; the animal has no interest in eating Pseudoanorexia: secondary anorexia hungry, but appears unable to eat oral pain, unpalatable diets or environmental stress. 7 O R A L C AV I T Y ORAL CAVITY Lips and oral mucosa Palate Tongue Teeth Mandible, maxilla Salivary Glands Dyce 9 CLINICAL SIGN Pseudoanorexia Abnormal movement of jaw Pain Unwilling to pick up toys/play ball Hypersalivation Failure to gain weight Halitosis Ceased grooming NOTHING 10 D E N TA L D I S E A S E Oral resorptive lesions (feline) Fractured teeth Malalignment/malocclusion Cleft palate Overgrowth (equine, rabbit, small mammals - herbivores) Abscess (any but rabbit common) Gingiviits/Periodontitis (canine most common) Gingivostomatitis (feline most common) BSAVA manual of gastroenterology 11  D E N TA L D I S E A S E - O V E R G R O W T H Rabbit molar spur Texasequinedentist.com #universityofsurrey Vetcentral.com 12  D E N TA L D I S E A S E BSAVA manual of gastroenterology Cat oral resorptive lesion #universityofsurrey 13 Canine periodontitis L I P S , O R A L M U C O S A , G U M S , PA L AT E Neoplasia Viral Soft tissue sarcoma Papillomavirus – all species Squamous cell carcinoma (feline) Calicivirus (feline) Melanoma Feine gingivostomatitis Sarcoids (equine) Reoviridae Trauma Bluetongue Penetrating injury/stick injury Picornavirus Tongue laceration Foot and mouth Inflammatory/immune mediated Congenital Eosinophilic granuloma complex (feline) Cleft palate, cleft lip Lip fold dermatitis (secondary pyoderma) 14 NEOPLASIA Feline squamous cell carcinoma Soft tissue sarcoma Fibrosarcoma 15 TRAUMA Vet Times 16 VIRAL Orf MSD Animal Health Papilloma Feline gingivostomatitis Vet Times 2013 17 http://csu-cvmbs.colostate.edu VIRAL - NOTIFIABLE Foot and mouth Bluetongue Institute of animal health Defra 18 I N F L A M M ATO RY Lip fold dermatitis Feline eosinophilic granuloma 19 SALIVARY GLANDS Salivary gland mucocoeles Sialadenitis Neoplasia Fossum, Small Animal Surgery 20 JAWS Fractures/trauma Mandibular symphysis fracture Bacterial Actinomyces bovis – lumpy jaw Abscess – penetrating injury Neoplasia 21 I N V E S T I G AT I O N History Thorough visual oral exam –sedate? Biopsy and histopathology Culture BSAVA Manual Viral swab PCR Imaging Standard radiographs not always useful (difficult to image area of concern) Dental radiographs are useful CT 22 OROPHARYNX OROPHARYNX Tonsils Cricopharyngeal muscles 24 CLINICAL SIGNS Dysphagia Retching Gagging/gulping Reduced appetite (pseudoanorexia) Weight loss 25 DISORDERS Neoplasia Polymyopathy and Polyneuropathy Squamous cell carcinoma Cranial nerves (IX, X and XII) needed for Sarcoma swallow reflex Lymphoma (rare) Muscles relax and contract Disorders of either can lead to dysphagia Cricopharyngeal achalasia Normally generalised signs Muscle doesn’t relax Congenital/genetic Cricopharyngeal dysphagia Relaxes at incorrect time (asynchronous) Fluoroscopy can differentiate the two 26 I N V E S T I G AT I O N Physical examination – visual inspection of oral cavity Mass, focal inflammatory Radiographs Difficult area to image CT or MRI Biopsy or histology Mass lesions Fluoroscopic swallowing study Dynamic radiographs – can see the https://www.youtube.com/watch?v=6cZIUrpxtig act of swallowing (4’50”) 27 OESOPHAGUS OESOPHAGUS Narrows at four locations: pharyngo- oesophageal sphincter gastro-oesophageal sphincter thoracic inlet base of the heart Long muscular tube 29 CLINICAL SIGN Regurgitation: species variation Most common sign in cats/dogs Should be fairly soon after eating Must differentiate from vomiting Reflux Hyporexia/pseudoanorexia Ptyalism (not true ptyalism) Weight loss 30 R E G U R G I TAT I O N Differentials of Regurgitation Physical obstruction Megaoesophagus Physical❖ Extra-luminal Extra-luminal ❖ Congenital Congenital Megaoesophagus obstruction Vascular ring anomaly Vascular ring anomaly ❖ Acquired Acquired Intra-thoracic Intra-thoracic mass mass Idiopathic Idiopathic Intra-luminal ❖ Intra-luminal Neuromuscular Neuromuscular disease disease Foreign body Toxicity Foreign body Stricture Toxicity Endocrine Stricture Tumour Endocrine (hypoadrenocorticism) (hypoadrenocorticism) Tumour Granuloma Inflammatory Functional Granuloma Lower oesophageal achalasia- ❖ OesophagitisOesophagitis Inflammatory Functional like syndrome ❖ Reflux syndromes Reflux syndromes Sliding hiatial hernia ❖ Lower oesophageal achalasia-like Aerodigestive ❖ Aerodigestive disorders disorders syndrome ❖ Sliding hiatial hernia 31  DISORDERS OF THE OESOPHAGUS Oesophageal foreign body Dogs Horses (choke) Cows Rare in cats 32 DISORDERS Narrowing Stricture Vascular Ring Anomaly Neoplasia (rare) Megaoesophagus Hereditary in some dogs Secondary to Vascular Ring Anomaly Generalised enlargement Lack of peristalsis Myastheia gravis – generalised muscle condition Neuropathy Oesophagitis Diverticula 33 I N V E S T I G AT I O N Plain Radiographs Fluoroscopy (swallowing study) Conscious Dynamic Left lateral (or both) Oesophageal air – megaoesophagus Endoscopy Foreign body Excellent for intraluminal contents and mucosal lesions Contrast Radiographs (barium) Foreign bodies, oesophagitis Neoplasia Can’t diagnose megaoesophagus Motility disorders 34 STOMACH  STOMACH Horse Ruminant Monogastric Today’s Veterinary Practice Hindgut fermenter Foregut fermenter 36 CLINICAL SIGNS Vomiting (only cat and dog) Cranial abdominal pain Anorexia (nausea, don’t want to eat)/reduced appetite Weight loss/reduced weight gain Reduced performance (horses) Abdominal distension Melena (digested blood coming out in stool) 37 VOMITING ACTIVE PROCESS Nausea Reduction in gastric/lower oesophageal sphincter and oesophageal motility, and increased retrograde motility of small intestine Retching Contraction of abdominal muscles and marked abdominal effort (NOT in regurgitation) Expulsion of gastric contents Simultaneous contraction of abdominal muscles and diaphragm → negative intrathoracic pressure → movement of gastric contents into oesophagus/mouth 38 DISORDERS Gastritis Foreign body Infectious Acute vs chronic Bacteria Primary vs secondary Pyloric stenosis Helicobacter (cats/dogs) Ulceration Parasitic Performance animals Distension Trichostrongylus Primary vs secondary Bloat Ostertagia GDV Haemonchus Displaced abomasum Viral Neoplasia (uncommon) Gastric impaction Parvovirus Adenocarcinoma Lymphoma Leiomyosarcoma/- Traumatic myoma in muscle reticuloperitonitis layers 39 DISORDERS- DISTENSION Distension Bloat GDV Gastric impaction Grain overload Displaced abomasum 40 I N V E S T I G AT I O N Visual and physical examination Abdominal swelling Endoscopy Palpation Mucosa – ulcer, mass Auscultation Foreign body – diagnosis and retrieval Percussion Mucosal/submucosal biopsy and histology Radiographs Exploratory surgery Size, shape, distension, foreign body Diagnosis and removal of foreign body Biopsy and histology Ultrasound Wall thickening/layers, foreign body, Faecal analysis stenosis Parasites Blood work: Haematology, Biochemistry, Electrolytes Anaemia, WBCs, electrolyte abnormalities 41 SMALL INTESTINE SMALL INTESTINE Duodenum Jejunum Ileum The glass horse 43 CLINICAL SIGN Hyporexia/anorexia OR Polyphagia Weight loss/poor growth Abdominal pain (colic) Abdominal distension Hypoproteinaemia (low alb) Ascites/oedema Dehydration/Collapse Decreased OR increased gut sounds (borborygmi) Flatulence Diarrhoea 44 SMALL V S LARGE INTESTINAL DIARRHOEA Small Intestinal Large Intestinal Frequency Normal to mild increase Increased Urgency Normal Increased Mucous No Yes Straining No Yes Blood Melena Haematochezia (fresh blood) Volume Increased Normal to mild increase 45 DISORDERS Obstruction Foreign body Neoplasia Neoplasia Lymphoma Adenocarcinoma Sarcoma Intussusception Volvulus in dogs (are) 46 DISORDERS Ulceration Parasitic Inflammatory Primary vs secondary Giardia Lymphocytic Cryptosporidium Plasmacytic Bacterial Coccidia Eosinophilic Salmonella Cooperia E.Coli Strongyloides Toxin ingestion Campylobacter Nematodirus Clostridium Toxocara Trichuris Gut stasis Lawsonia Tapeworm Common in rabbits Mycobacteria Hookworm Colic in horses Not uncommon in small Viral animals Parvovirus Fungal (rare in UK) Coronavirus BVDV Rotavirus 47 I N V E S T I G AT I O N Palpation Solid structure Auscultation Increased or decreased gut sounds Minimum database: haematology, biochemisty, electrolytes Inflammation Protein levels Electrolytes disturbances Folate and cobalamin (B12) Faecal analysis 48 I N V E S T I G AT I O N Radiographs Endoscopy Gas distenstion Duodenal and ileal Soft tissue opacity intestinal lumen Mass effect Mucosal biopsy Radio-dense FB Exploratory surgery Ultrasound Therapeutic Obstruction Biopsy and histology Neoplasia Intestinal thickening Foreign body 49 LARGE INTESTINES THE LARGE INTESTINES: HIND GUT FERMENTERS The glass horse Ileum and Caecum from the left Msdmanual.com 51 THE LARGE INTESTINES: SIMPLE MONOGASTRIC DIGESTION Hill’s Pet Nutrition Msdmanual.com 52 CLINICAL SIGNS Diarrhoea Weight Loss (species dependant) Change in appetite (variable) Constipation Faecal incontinence (rare) Abdominal pain Pdsa.org 53 DISORDERS Foreign body (uncommon) Viral Coronavirus Parvovirus Inflammatory (non-specific) Neoplasia Rotavirus Lymphocytic Adenocarcinoma BVDV Plasmacytic Lymphoma (rare) Benign polyp Eosinophilic Parasitic Giardia Intussusception (rare) Tritrichomonas Trichuris Bacteria Tapeworm Salmonella Campylobacter Fungal E. coli Histoplasma Clostridia Candida 54 G R A N U LO M ATO U S C O L I T I S Boxer, French Bulldog E. coli 55 DISORDERS OF THE LARGE INTESTINE: COLIC Colic = Abdominal Pain Impaction (Caecal, Colonic) Left dorsal displacement (Nephrosplenic Entrapment) Right dorsal displacement Volvulus Right Dorsal Colitis (horses) Secondary to NSAIDs Msdmanual.com The glass horse 56 DISORDERS OF THE LARGE INTESTINE: ILEUS Rabbits Poor diet Poor dentition BSAVA Rabbit Surgery, Dentistry and Imaging 57 I N V E S T I G AT I O N Digital rectal palpation (small animals) Haematology and Biochemistry Faecal consistency/colour Evidence of inflammation (non-specific) Abnormal texture Faecal analysis Foreign Bodies Bacterial culture Mass lesion PCR Rectal Palpation (horses, cows) Parasitology Colic: distended loops, abnormal position Abnormal texture Faecal consistency/colour Abdominal palpation Mass Constipation 58 I N V E S T I G AT I O N Radiographs Exploratory Surgery Faecal impaction Limited in this area Colonic distension Risk of dehiscence and peritonitis Foreign body Confirmed mass, intussusception or Ultrasound (limited in pelvic cavity) megacolon Intussusception Don’t do surgical biopsies Foreign body Intestinal wall changes Endoscopy Mucosal abnormalities Intraluminal mass/foreign body Mucosal and submucosal biopsies Histology and F.I.S.H analysis (HUC) BSAVA Manual of Endoscopy 59 RECTUM AND ANUS RECTUM AND ANUS Rectum Anus Anal sacs (dogs and cats) Fossum Small Animal Surgery 61 CLINICAL SIGNS Tenesmus Straining to defecate Irritation Scooting Licking Biting Change in faecal shape Thin, ribbon-like stool 62 DISORDERS Strictures (uncommon) Anal Sac Disease Neoplasia Impaction Benign Neoplasia Polyp Abscess Malignant Anal furunculosis/fistsulae Adenocarcinoma Congenital Lymphoma Atresia ani Rectal Prolapse Rectovaginal fistulae Perianal adenocarcinoma Normally secondary Fossum Small Animal Surgery Perineal Hernia 63 I N V E S T I G AT I O N Visual Inspection Rectal digital palpation Fine needle aspirate Biopsy Manual of small animal soft tissue surgery 64 DISORDERS OF THE GIT Clinical signs and history help to specify location Don’t’ forget systemic or concurrent disease Can affect both small and large intestines Differential lists can be very long Diagnostic tests should be appropriate to the location and the species Client communication is key 65