Approach to Vomiting in Companion Animals 2024 PDF

APPROACH TO… VOMITING IN C O M PA N I O N A N I M A L S PRIYA SHARP LEARNING OBJECTIVES Construct a differential diagnosis list based on vomiting as a clinical presentation and choose appropriate diagnostics Determine appropriate medical and surgical intervention...

APPROACH TO… VOMITING IN C O M PA N I O N A N I M A L S PRIYA SHARP LEARNING OBJECTIVES Construct a differential diagnosis list based on vomiting as a clinical presentation and choose appropriate diagnostics Determine appropriate medical and surgical interventions in the management and treatment of diseases characterised by vomiting Determine appropriate prognosis, and the welfare implications of treatment options Determine control measures appropriate for disease prevention 2 W H AT I S V O M I T I N G ? #universityofsurrey 3 W H AT I S V O M I T I N G ? ACTIVE PROCESS NAUSEA Pro-dromal signs Depression, shivering, hiding, yawning, lip-licking Increased salivation and swallowing RETCHING Forceful contraction of abdominal muscles and diaphragm EXPULSION Pressure changes = movement of gastric contents to oesophagus and mouth As the vomited material passes through the pharynx, respiration is inhibited and the nasopharynx and glottis close to prevent aspiration 4 W H AT I S R E G U R G I TAT I O N ? Normal, voluntary process Expulsion of material from pharynx or oesophagus Nausea Retching Abdominal contraction 5  W H Y D O O U R PAT I E N T S V O M I T ? Neurological input from the vestibular nucleus Chemoreceptor Drugs Toxins Trigger Zone Uraemia Infections Cerebral disease Disease of GI tract Liver Pancreas Vomiting Centre Genitourinary Peritoneum Vomiting 6  W H Y D O O U R PAT I E N T S V O M I T ? Gastrointestinal Extra-gastrointestinal conditions conditions Gastric Small intestinal Large intestinal Metabolic/endocrine Toxins or conditions conditions conditions disorders Drugs Abdominal Neurological Usually → Diarrhoea disorders disorders or Constipation #universityofsurrey 7 GASTROINTESTINAL CONDITIONS Gastric Small Intestine Large Intestine Gastritis Inflammation (IBD) Inflammation (IBD/Colitis) Gastric ulceration Neoplasia Obstipation Neoplasia Foreign body Infection Motility disorders Intussusception Neoplasia GDV Infection Foreign body Pyloric stenosis Hiatal hernia 8 EXTRA-GASTROINTESTINAL CONDITIONS Metabolic/endocrine Toxin/Drugs Abdominal Neurological Diabetic ketoacidosis NSAIDs Pancreatitis Vestibular Hypoadrenocorticism Antibiotics Peritonitis Pain Renal disease Ciclosporin Neoplasia Smell Hepatic disease Methimazole Hepatobiliary disease Trauma Endotoxaemia Chemotherapy Pyometra Encephalitis Electrolyte disorders Poisons Hyperthyroidism 9 VOMITING-CAUSES Gastrointestinal conditions Extra-gastrointestinal conditions Gastric Small intestine Metabolic/endocrine Toxins/drugs Gastritis Inflammation Renal disease NSAIDs Ulceration Foreign body Hepatic disease Chemotherapy Motility disorders Intussusception Diabetic ketoacidosis Poisons Gastric distension and Infection Hypoadrenocorticism volvulus Neoplasia Foreign body Pyloric stenosis Hiatal hernia (Large intestine) Abdominal Neurological Inflammation Pancreatitis Vestibular Obstipation Peritonitis Pain Hepatobiliary disease Smell Pyometra Trauma Encephalitis 10 I N V E S T I G AT I O N O F V O M I T I N G History Acute vs chronic GI vs Extra GI Physical examination Diagnostic plan Laboratory testing Imaging Surgical exploration Cytology/histopathology Infectious disease testing 11 H I S TO R Y TA K I N G Duration? Change in diet? How often/how severe? Thirst/urination What? (bile, food, haematemesis) Pain? Any toxin/drug exposure? Any other signs? Scavenging/FB PITFALLS IN HISTORY TAKING Faecal consistency Not taking patient signalment into Demeanour account Weight loss Not taking previous medical history into account Appetite Not giving full consideration to diet Being misled by the owner 12 P H Y S I C A L E X A M I N AT I O N Specific Signs Serious signs Painful Pyrexia Bloated Tachycardia Icterus Weak pulses Solid structure Dehydration Head tilt Focused investigation Rapid Investigation/Txt 13  L A B O R ATO RY W O R K Dehydration PCV TS Glucose Minimum Hypo/Hyperglycaemia Database Urea/Creatinine PCV/Total solids Azotaemia Glucose Pre-renal (GI disease) Urea/Creat Electrolytes Urea with GI bleeding Electrolytes Urine Hypokalaemia Urine Na:K ratio Specific gravity Dipstick 14 L A B O R ATO RY W O R K – F U R T H E R T E S T I N G Full haematology, biochemistry Coagulation testing Cortisol Bile acids Total T4 (cats) cPLI, fPLI 15 INFECTIOUS DISEASE TESTING #universityofsurrey 16 RADIOGRAPHY #universityofsurrey 17 U LT R A S O U N D 18 ENDOSCOPY Gastric FB Gastric ulcer Gastric neoplasia Gastric/duodenal inflammation 19 Images courtesy of Hall.E. (2015) In practice 37 (155-168) S U R G I C A L E X P LO R AT I O N Indications Gastric / Intestinal foreign body Gastro-intestinal neoplasia GDV Abdominal neoplasia Septic peritonitis Pyometra 20  T R E AT M E N T ACUTE CHRONIC SYMPTOMATIC DISEASE SPECIFIC Anti-emetics Surgery Serious Clinical Analgesia Dietary Signs IVFT Chemotherapy Anti-acids GIT specific Gastric protectants Extra-GIT conditions 21 V O M I T I N G - T R E AT M E N T Anti-emetics Symptomatic therapy Maropitant Anti-acids Metoclopramide Gastroprotectants Ondansetron Disease specific therapy Analgesia Gastrointestinal Opioids Tramadol Extra-gastrointestinal Lidocaine Intravenous fluids Hartmann’s Sodium chlorides (0.9%) Colloids? Potassium supplementation 22 S Y M P TO M AT I C T H E R A P Y – A N T I - E M E T I C S Maropitant Metoclopramide (Ondansetron) Can you exclude an obstruction? 23 S Y M P TO M AT I C T H E R A P Y – A N A LG E S I A Opioids Methadone, Buprenorphine Tramadol Lidocaine NSAIDs 24 S Y M P TO M AT I C T H E R A P Y – I N T R AV E N O U S FLUIDS Hartmann’s Sodium chloride (0.9%) Colloids? Potassium supplementation? Base rate on clinical condition of patient Calculate maintenance and ongoing losses 25 S Y M P TO M AT I C T H E R A P Y Anti-acids Omeprazole Proton pump inhibitor Ranitidine, famotidine H2 blocker Gastric protectants Sucralfate 26 D I S E A S E S P E C I F I C T H E R A P Y: GASTROINTESTINAL EXAMPLES 27 D I S E A S E S P E C I F I C T H E R A P Y: E X T R A - GASTROINTESTINAL EXAMPLES 28 PROGNOSIS Depends on underlying condition! Gastritis Pancreatitis Diabetic ketoacidosis 29 PREVENTION 30 SUMMARY Is it vomiting or regurgitation? Is it acute or chronic? Gastrointestinal or Extra-gastrointestinal Need a thorough investigation and methodical approach Sometimes symptomatic treatment appropriate but be prepared to investigate if no improvement 31