Stomach Diseases in the Dog and Cat

Stomach Diseases in the Dog and Cat Clinical Signs Vomiting is the most common sign ►food ► bile ► mucus or foam ► fresh blood ►coffee-grounds (digested blood) ► projectile outflow obstruction ► may or may not be associated with eating Other Clinical Signs • • • • • • • • anorexic hypersalivation abdominal pain retching - non-productive → GDV! melena (digested blood) weight loss dehydration lethargic Metabolic Consequences of Vomiting Electrolyte imbalances: loss of : Na+, K+, CL-, H+, HCO3-, H20 * hypokalemia most common Metabolic Consequences of Vomiting • metabolic acidosis – most common with severe vomiting – loss of bicarbonate – dehydration • poor perfusion » lactic acidosis (acidic) metabolic alkalosis -loss of HCL -upper GI obstruction -obstruction proximal to pancreatic duct where bicarbonate excreted Hypochloremic Metabolic Alkalosis → **think upper GI obstruction Acute Gastritis: Vomiting < 3 days • Dietary → Dogs > Cats – high fat diet – over-eating – garbage • high fat, enormous amount • food poisoning – bacterial toxins – food hypersensitivity • Foreign body – young - history of chewing – any age dog or cat – material in vomit or feces – material found in environment – fed a bone • Drugs – NSAIDs • aspirin, ibuprofen, carprofen, deracoxib, meloxicam, etc. – Corticosteroids • prednisone, dexamethasone – Chemotherapy agents – Antibiotics • Chemical irritants: – solutions containing heavy metals, cleaning agents, fertilizers • Bacterial toxins: – Staphalococcus enterotoxin • Plants: – GI irritants – renal failure (Easter lily), liver failure (Sago palm, mushrooms) • Viruses Unvaccinated puppies and kittens »Distemper, Parvovirus - dogs »Panleukopenia – cats Parasites Stomach worms Physaloptera → dog Ollulanus tricuspis → cat Intestinal worms: Toxocara (rounds) Ancylostoma (hooks) Isospora (coccidia) Food Hypersensitivity Cats – vomiting Dogs – vomiting and diarrhea Anaphylatic Reaction • Bee stings, spider bites • Vaccination reaction • Drugs • Chemicals Metabolic Disease Young animals • kidney disease/failure • liver disease/failure • diabetes mellitus • Addison’s disease • shock • sepsis • toxins: ethylene glycol Adults •pancreatitis •diabetic ketoacidosis •pyometra/prostatitis •shock •sepsis •toxins: ethylene glycol •Addison’s disease •kidney disease/failure •liver disease/failure Physical Exam • Palpate foreign body or mass • Palpate abdominal pain • String under the tongue – Linear foreign body • Can be normal in acute gastritis Work-up • Not all acute gastritis patients need any diagnostic testing • Very young → think foreign body • Very old → think metabolic disease • Depressed, lethargic, abdominal pain, pyrexic, severely dehydrated → work-up needed Clinical Pathology • CBC} • chemistry panel } • urinalysis} *metabolic disease (kidney, liver, pancreas) • fecal analysis • can all be normal in acute gastritis Radiographs • Abdominal radiograph – young dog or cat – foreign bodies – older animal – pancreatitis, history of foreign bodies • Can be normal in acute gastritis. Diagnosis • History, clinical signs and physical exam • Rule out the obvious (foreign body, parasites, toxins, viruses, metabolic). • If clinical signs are not severe, no further work-up necessary at this time. • If no response in 24 hours more diagnostics needed Treatment • NPO 24 hours • Bland diet: low fat, low fiber, highly digestible, high in carbohydrates • Antiemetics: metoclopramide (Reglan) • H-2 blockers: ranitidine (Zantac), famotidine (Pepcid AC), • Proton pump inhibitor: omeprazole (Prilosec) Chronic Gastritis: Vomiting > 3days • • • • • vomiting anorexic weight loss abdominal pain hematemesis – melena – polydipsia – anemia – depression Physical Exam • • • • • pale mucous membranes – anemia abdominal pain abdominal mass, foreign body melanic stool on rectal or thermometer weight loss Diagnostic Plan Vomiting Metabolic Gastrointestinal Metabolic Work-up • • • • CBC Chemistry panel Urinalysis Fecal CBC: Anemia non-regenerative: chronic disease, iron deficiency anemia regenerative: acute gastric bleeding Eosinophilia – parasites, Addison’s Chemistry panel • BUN > 60 with normal creatinine *GI bleeding is a high protein meal Gastrointestinal work-up • Plain radiographs – retained food, gas distention, foreign body, displaced stomach, pancreatitis • Contrast studies - barium or iohexol – filling defects –ulcers, masses – thickened gastric wall –inflammation, neoplasia, fungal, pythium Radiographs • Plain and Contrast studies – over-distended gas filled stomach • gastric outflow obstructed – foreign body, mass, hypertrophy • decreased motility – ileus Ultrasound of Abdomen • thickened stomach wall • mass in stomach wall • small intestinal/large intestinal thickening or mass • enlarged messenteric lymph nodes Endoscopy • Examination of the gastric mucosa: – – – – – – – erosions large ulcers abnormal mucosa color masses or thickened, irregular mucosa foreign body, retained food Must biopsy for histopathological examination!! Treatment • Dietary: low fat, low fiber, new protein source (novel diet), high carbohydrate • H-2 blockers/proton pump inhibitor – decrease acid and some enhance motility • Sucralfate • Metoclopramide Chronic Gastritis: Endoscopic/Histopath findings • • • • • Chronic atrophic gastritis Chronic hypertrophic gastritis Lymphocytic/plasmacytic Eosinophilic Helicobacter pylori, H. felis Gastric Ulcers – Mucosal Barrier breaks down • mucous and bicarbonate rich layer – Back diffusion of acid into the mucosal lining and subcutaneous tissue – Break down of mucosal layer and underlying layers: submucosa, muscularis, serosal Etiology • Ischemia – Reduced blood supply to mucosa causes normal back-diffusion of gastric acid to damage gastric wall • Exogenous agents – alter and damage mucosa Etiology Drugs, Drugs, Drugs…………. Metabolic diseases renal - uremic toxins and gastrin liver - ischemia, gastrin, histamine, bile acids, ammonia neoplasia: mast cell tumors - release histamine gastrinomas – release gastrin neoplasia invades the mucosa directly inflammation helicobacter stress, shock, trauma, hypotension, neurologic disease, severe illness Clinical Signs • vomiting, hematemesis – fresh blood or coffee grounds • always indicates gastric ulceration!! – melena, anemia, nausea, variable appetite, polydipsia, abdominal pain – Perforated ulcers → peritonitis, shock and death • Physical Exam – abdominal pain, anemia, melena • Bloodwork – Regenerative anemia or non-regenerative anemia – Neutrophilia +/- left shift – Hypoproteinemia (blood loss) – Fecal occult blood positive • Radiographs – Contrast may outline craters and fissures – May be normal • Endoscopy: best evidence (but diffuse microscopic ulcerative lesions possible) – Biopsy but around edges of ulcer- not in center or will perforate!! Treatment • Excessive bleeding and anemia → surgery • Medical: – H-2 blockers, proton pump inhibitor, sucralfate, misoprostol – Antibiotics? – NPO and IV fluids if actively bleeding – Bland diet Gastric Retention/Delayed Emptying • Motility Disorders (functional obstruction) – metabolic dz, drug induced, inflammation induced, ulcers, infiltrative disease • Gastric outflow obstructions (physical obstruction) – foreign bodies, tumors – CHPG – chronic hypertrophic pyloric gastropathy • Toy breeds primarily but can be seen in large dogs Clinical Signs • Usually post-prandial vomiting and can be projectile • Usually undigested food in vomitus • Rarely bile stained • If congenital problem: thin, stunted • Animal usually wants to eat but some can be painful and have a depressed appetite Diagnosis • tentatively based on signalment, history and clinical signs Radiographs: over distended stomach filled with air or food; presence of food in stomach more than 1224 hours after last meal; narrowed pyloric antrum with contrast study Diagnosis • Endoscopy not very helpful in motility disorders – may see redundant tissue in area of pylorus – foreign bodies, ulcers, tumors, inflammation, obstructive polyps or tumors • Exploratory Surgery: very valuable when suspect outflow lesion – may also correct problem! Treatment • Motility disorder without physical obstruction – Metoclopramide, Ranitidine, Nizatidine, Cisapride • Gastric Outflow Obstruction – Correct electrolyte, acid-base, fluid deficits – Surgery: pyloromyotomy/plasty (CHPG), gastrotomy (FB), biopsy +/- gastrectomy (neoplasia) Gastric Dilatation-Volvulus Syndrome (GDV) • Clock-wise torsion of stomach with pylorus coming up and over fundus and cardia (V/D view) – Creates compartmentalization of stomach which can be viewed on radiograph – Pylorus and Spleen displaced • Stomach fills with gas and fluid due to lack of pyloric outflow, overgrowth of gas producing bacteria, increased fluid secretion into stomach Clinical Signs • Patient begins to become uncomfortable as stomach distends rapidly over a few hours and often tries to relieve gas/fluid by belching but unproductive retching is all that happens – very characteristic sign!! Pathophysiology • Bloated stomach compresses caudal vena cava→ severe drop in venous return to heart → decreased cardiac output → severe hypotension→ severe shock • Once decompress stomach, blood flows again into organs and may see reperfusion injury (free oxygen radical damage) in tissues (spleen thrombosis, infarction) Physical Exam Findings  bloated abdomen – gastric tympany (left side) • • • • • pale mucous membranes very weak pulses tachycardia tachypnea collapse Treatment • Emergency: – Decompress: stomach tube, trochar only if very difficult to pass tube – 2 IV lines: shock dose of fluids • Avoid rear limb catheters – poor perfusion – Sequelae: Fatal cardiac arrhythmias (usually in first 24-48 hrs but can occur up to one week later) → VPC’s and V-tach; DIC, reperfusion injury, gastric necrosis Treatment • After stabilize patient: – Emergency surgical gastropexy to prevent from occurring again! – Refer to another hospital if can’t do in your practice. • Prognosis: guarded, depends on gastric condition at surgery, survival during and after surgery, sequelae Gastric Neoplasia • Dogs: Adenocarcinoma most common! – lymphosarcoma, leiomyosarcoma • Cats: lymphosarcoma most common! • Clinical signs suggest chronic disease with or without blood in vomit/feces • Diagnosis: contrast rads, endoscopy, surgery • Treatment: resection for Adenocarcinoma, chemotherapy for lymphosarcoma • Prognosis: guarded to poor for long-term Case #1 Signalment & History • 7 year old, F/S, Cocker Spaniel • depressed appetite for 2 weeks and has progressed to anorexia for the last 2 days • vomiting noted for 2 weeks but progressed 3 days ago occurring 3-4 times daily and consists of dark brown vomitus with mucus • current on DHLP-P, RV, Heartworm testing/prevention Physical Exam • temp=101.0; HR=100 bpm; RR=40 bpm; weight= 14.5 kg – – – – – depressed dry, pink mm 8% dehydrated abdomen painful on palpation *dark brown/black colored stool on rectal exam Problems • depressed appetite/anorexia x 2 weeks • chronic vomiting (>2 weeks) - dark brown/black • painful abdomen • melena • dehydrated • depressed Differential Diagnoses for Chronic Vomiting • Non GI diseases/Metabolic Disorders – – – – – – – renal disease liver disease hypoadrenocorticism diabetes mellitus chronic pancreatitis pyometra/prostatitis neurologic disease DDx Chronic Vomiting • GI Diseases – – – – Parasites - ascarids, Physoloptera, Ollulanus Helicobacter pylori (?) Foreign bodies Pyloric Outflow obstructions • • • • • Masses - Neoplasia, Pythium Hypertrophy- gastrin excess, HPG (small breeds) Stenosis- congenital or acquired Foreign bodies Motility disorders- drugs, metabolic, inflammatory, neurologic Chronic Vomiting • Gastric ulcers – drugs (aspirin, ibuprofen, other NSAIDs, corticosteroids) – renal and liver disease – hypoadrenocorticism – neurological disease – enterogastric reflux - bile – gastric hyperacidity- gastrinoma, systemic mastocytosis – neoplasia - Adenocarcinoma, Lymphosarcoma – Helicobacter pylori?? Diagnostic Plan • • • • • • • • CBC Chemistry profile Urinalysis Fecal exam- parasites; occult blood Abdominal radiograph, Barium study Abdominal Ultrasound Endoscopic exam Surgical exploratory Extended diagnostics • • • • Bile acids assay ACTH stimulation test Gastrin level (gastrinoma) Histamine level (mast cell tumor) • CBC – PCV=26%, MCV=55, MCHC=29 • Chemistry Profile – BUN=56, albumin=2.3, globulin=2.2 • • • • • Urinalysis - wnl Fecal - negative Abdominal radiograph - wnl Abdominal ultrasound - wnl Bile acids assay- pre and post prandialnormal range Endoscopic Exam • Histopathology of biopsy – gastric ulcer - no evidence of neoplasia or infectious organisms • Gastrin serum level – normal • Histamine serum level – normal Treatment • Histamine-2 receptor blocker – ranitidine (Zantac) – famotidine (Pepcid AC) • • • • • omeprazole (Prilosec)- proton pump inhibitor sucralfate (carafate)-binds to submucosa misoprostol (Cytotec)- prostaglandin analog bland diet (low in fat) surgery if hemorrhage profuse Case #2 Signalment and History • 12 year old male/neutered, mixed breed dog • Began vomiting yesterday and has not eaten today • Vomited three times last night and twice this morning, mostly food and foam • Current on vaccinations, heartworm prevention/testing • Eats purina dog chow but does occassionally get table scraps Physical Exam • • • • Weight=8 kg, good body condition Slightly depressed mentation Mucous membranes - pink, tacky Temp= 102.5,HR=120, RR=30, pulses strong • abdominal palpation - relaxed • rectal exam - empty Problems • Acute vomiting (< 3days) • slightly dehydrated • depressed appetite/anorexic Differential Diagnoses • dietary indiscretion • bad food “food poisoning” • foreign body • drugs • chemical irritants • toxins • parasites • food allergies • metabolic disease – uremia – liver disease – endocrine disease • DM; Cushing’s; Addison’s – pancreatitis – sepsis – neurologic disease Diagnostic Plan • • • • • CBC - WNL Chemistry panel- WNL Urinalysis- WNL Lipase- WNL Abdominal radiograph- WNL Treatment • Dietary restriction (NPO or No Food) – 24-48 hours • Bland diet – 3-5 days (low in fat and fiber) • Parenteral fluid therapy if needed • Anti-emetic drugs if needed – Metoclopramide (Reglan) – Phenothiazines (Chlorpromazine) • +/- H-2 blockers – Ranitidine (Zantac), Famotidine(Pepcid AC) If no response to therapy: • Consider pancreatitis – Further treatment with NPO, IV fluids, etc. – Further diagnostics • Abdominal Ultrasound • Exploratory Laparotomy with biopsies • Consider Gastrointestinal Ulcer/Neoplasia/ Foreign body/Pyloric outflow obstruction/ Pythium/IBD/Biliary reflux • Upper GI Barium study • Endoscopic exam with biopsies • Exploratory Laparotomy with biopsies Gastric Foreign Body of Poodle Hair (Trichobezoar) Pyloric area: Lymphosarcoma Physaloptera: The stomach worm