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GI Part 2 - Esophagus & Stomach

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sihirlifil's version from 2018-02-04 01:04

Esophagus (Regurg)

Question Answer
Esophageal dz: presenting complaints"Vomiting" (owner tells you) vs regurg
Coughing
Gaggins
Hematemesis
Ptyalism
Dysphagia, multiple swallow attempts
Odynophagia (pain on swallowing)
V or R: Abdominal effortV: +
R: -
V or R: Prodromal nauseaV: +
R: - (+ if chronic)
V or R: BileV: +/-
R: -
V or R: FoamV: +/-
R: +
V or R: pHV: Acidic
R: neutral
V or R: Digested or undigested foodBOTH can have undigested
Digested food only possible with vomiting
Fxn of esophagusTransport food and liquids
2 categories of esophageal disease?Can't transport food/liquid (obstruction, fxn problem)
Hurts to transport (irritation, inflammation)
Ddx for esophageal obstructionFB
Mass/granuloma
Stricture
Vascular ring anomaly
Ddx for esophageal functional probMegaesophagus
Lower esophageal sphincter achalasia
Dysautonomia
Diverticula/fistula (anatomic)
Ddx for esophageal inflammationEsophagitis
Esophageal ulcer
Mass
MOST COMMON differential for regurgEsophagitis (2ry to any cause of vomiting)
3 most common ddx of regurgEsophagitis
Megaesophagus
FB
Critical diagnostics for regurgThoracic & cervical radiographs (r/o obstructive or anatomic dz)
Critical to guide the next dx steps
Causes of esophagitisVomiting from any cause (FB, IBD, pancreatitis...)
Medications
Gastroesophageal reflux (2ry to ANX, abnormal LES fxn/anatomy (hiatal hernia), brachycephalic airway syndrome)
What's going on here?
Wtf?
Hiatal hernia (cz of esophagitis)
May be visible on survey rads, if not can do contrast study with pressure on abdomen (Radiolucent paddle)
Esoph Dx: what are you ruling out?1: obstructive esoph dz with radiographs, esophogram
Fxnl: Esophogram, abdominal pressure study
Esoph Dx: how do you get the DEFINITIVE dx?Endoscopy
Esoph Dx: when is diagnosis a 'best guess?'When there is a clear other cause of vomiting
Esophagitis can lead to??STRICTURES
Which meds do we have to watch out for with the esophagus?Doxycycline
Clindamycin
what's goin on
Esophageal stricture (endoscopy)
Esophagitis tx: 1st stepID & (if possible) treat the cause of vomiting
Esophagitis tx: 2nd step (after tx vomiting)Symptomatic
Soft food, small frequent meals
For pain: Surcralfate, barium, lidocaine slurry
Esophagitis tx: 3rd step (after v+ tx & symptomatic)Prevent damage to esophagus
Esophagitis tx: what drug for prevent dmg to the eso?Omeprazole (proton pump inhib) (1-2mg/kg PO q12 for 1-2 wks, then wean)
Preferred tx for esophageal FBEndoscopic removal!
Risks of endoscopic FB removalEsophageal perforation, stricture formation
After endoscopic FB removal, how can we prevent stricture?Feeding right away, small frequent soft meals, PPI
Whats the problem?
Esophageal FB
Esophageal stricture: CSRegurg of food
Fluids/slurry food may be ok
Esophageal stricture: DxThoracic radiographs (+/- contrast)
Endoscopy = dx AND therapeutic!
Whats the problem?
Esophageal stricture
What is this procedure?
Balloon dilation of esophageal stricture via endoscopy (takes 2-5 times average)
Esophageal stricture: TxBalloon dilation via endoscopy
Bougienage
This patient presented for regurg:
Megaesophagus
3 classifications of megaesophagusTransient vs Permanent
Congenigal vs Acquired
If acquired: 2ry vs Idiopathic
(congential megaesoph breeds)(Mini schnauzer, wire-haired fox terrier, Great Dane, Irish Setter, Newfoundland, Shar Pei, Lab Retriever)
Cz of aquired, 2ry megaesophagusEsophagitis
Esophageal obstruction
Neuromuscular: MG, polyneuropathy/myopathy, vagal/spinal damage
Endocrine: Addisons, HypoT4
Toxins (lead, OP, botulism
Neoplasia (thymoma)
Megaesoph dx: MGAChR Ig (25-50%)
Megaesoph dx: polyneuropathy/myopathy2M titer
Nerve/muscle biopsy
Megaesoph dx: AddisonsACTH stim
Megaesoph dx: HypoT4TSH panel
Megaesoph dx: LeadCBC clues
Megaesoph dx: NeoplasiaRads & US
CT
Important to consider when treating megaesophagus:Concurrent aspiration pneumonia! Must tx this too
Megaesophagus: txTreat cause (if treatable) & aspiration pneumonia
+/- prokinetics
Small frequent low fat meals
Elevated feedings
PPI
Who benefits most from prokinetics as tx for megaesophagus? why?CATS b/c 1/3 of esoph is smooth muscle (dogs all striated)
What is this?
Bailey chair!
T/F Megaesophagus is permanentF! Can resolve spontaneously (greater chance if treatable etiology e.g. addisons)
If megaesophagus is 2ry to MG, whats the prognosis?50% response to treatment
Which kind of meegaesph has the worst prognosis?Idiopathic
Negative prognostic indicator = aspiration pneumonia
Esophageal mass: DdxInfectious, inlam, neoplastic, OR combinations!
Esophageal mass: e.g. of combinations (infx, inflam, neoplastic)Spirocerca lupi
Granuloma: OSA/FSA
If you see this esoph on necropsy in Grenada, top ddx?
Spirocerca lupi
(Rare esoph dz)(Diverticula, fistula, vascular ring anomaly)
(Rarer esoph fxn dz)(Dysautonomia: autonomic neuropathy with CS urinary retention, dribbling, lack of lacrimation. grave prognosis
LES achalasia: LES not opening approptirately)
Signalment clues: signs at weaning, think...Vascular ring or congenital megaesophagus
Signalment clues: YoungCongenital megaesophagus
Vascular ring anomaly
FB
Signalment clues: AdultMegaesophagus
Neoplasia
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Stomach (Acute vomiting)

Question Answer
Approach to vomiting patientStable or unstable?
Tx surgical or medical?
Cause of vomiting? (intra vs extra-GI)
How will you decide stable vs unstable via PE?Hydration/perfusion parameters
Pain level
Stable or unstable: CBCSigns of anemia
Hemoconcentration
Stable or unstable: ChemSigns of protein loss
Low albumin?
Panhypoproteinemia?
Stable or unstable: Electrolytes/BGSigns of obstruction
Surgical vs medical BEST INITIAL DX TESTRADIOGRAPHS
R/o obstruction
Vomiting pt: What will rads show you?(R/o: obstruction)
Functional = rare
Mechanical: FB, torsion, pyloric outflow obstruction (hypertrophy or mass)
Which surgical conditions can be r/o via rads?Septic peritonitis, pneumoabdomen
Things to look for on radsPyloric obstruction?
FB? (linear?)
Dilation?
Gas outside GIT?
Effusion?
Whats happening
(linear FB? check nots)
How do you decide whether to hospitalize vomiting patient?Mental checklist q's: Stable/unstable & surgical/medical
Extra-GI causes of vomitingHepatobiliary
Renal
Pancreatitis
Endocrine (HyperT4, Addisons)
Peritonitis/sepsis
Neuro
CVS
Intra-GI: VascularTorsion
Blood clot
Lymphangiectasia
Intra-GI: InfxViral
Bacterial
Parasitic
Fungal
Intra-GI: ToxinMedication
Intra-GI: AutoimmuneIBD
Intra-GI: Metabolic(related to extra-GI)
Intra-GI: MotilityFunctional or mechanical obstruction
Intra-GI: Neoplasia(yep)
Intra-GI: Developmental/genetic(Certain PLE disorders)
#1 common cz of vomitingDietary indiscretion
Others: diet change, new/different food, trash
Besides dietary indiscretion, acute gastritis can also be caused by...FB (obstructive & non)
Drugs/toxins
Infx
Systemic (extra-GI)
Tx of acute gastritis: STABLENPO 12h
SQF 10mL/kg
Anti-emetics (maropitant, ondansetron, dolasetron)
Tx of acute gastritis: UNSTABLEHospitalize, IV fluids
NOP 12-24h
Anti-emetics
Pain meds
Furhter dx
Parasites & protozoa can causeVomiting, decreased appetite, diarrhea
Anemia
Hypoproteinemia
Who is this
Giardia
What special thing do you find on chem with whipworms?Low Na:K ratio = MIMICS ADDISONS!
Diagnostics for parasites/protozoaFecal float, smear
Giardia ELISA (feces)
Tx for protozoa/parastiesFenbendazole for helminths & giardiasis
Empiric deworming if chronic signs
GDV
GDV predispositions?Large deep-chested breeds ((Lifetime risk great Danes 39%)
Small deep chested breeds too!
CS of GDVNon-productive retching --> Abdominal distention --> Collapse
GDV pathophysStomach torsion --> Occulsion of CVC --> decr venous return --> gas & fluid accum --> osmotic draw --> hypovolemia.
Splenic vessel torsion/avulsion --> hge/hypoperfusion -->shock
1st ER TX FOR GDVCVS STABILIZATION = FLUIDS!!!
GDV ER tx: after patient is on fluids, what next?Decompression (Trocharization, orogastric tube)
Diagnostics
Surgery
FB: how to decide if med or sx?Radiographs
FB: tx optionsSurgery
Endoscopic removal
Fluids, supportive care, see if passes on its own
FB tx: if owners want to wait & see if the FB passes, what should you discuss?Risk of perforation & compromising intestines
FB tx: indications for endoscopic FB removalGASTRIC FB ONLY! & re-take rads upon induction
Size of patient & FB
FB tx: CONTRAINDICATIONSHarm coming back through esophagus (e.g. pointy blade...)
Presence of food or barium
Risk of perforation
(Other mechanical obstructions)Pyloric (non-FB)
Mesenteric torsion
Intussusception
Stenosis/fibrosis (2ry to prev GI sx)
High parasite burden
How did this patient probably present?
Mesenteric torsion/volv = One of most painful patients EVER! Similar to GDV but abdominal distention maybe not as obvious. Life-threatening, SX EMERGENCY!!!
Patient comes in with acute (/chronic/intermittent) vomiting, abd pain:
Intussusception
SURGICAL EMERGENCY
Intussusception: underlying etiologiesParasitism
Parvovirus
Neoplasia
Intussusception: DxAbdominal palpation
Radiographs, Abd US
Gastric ulcers: CSVomiting
Anorexia
Melena, hematemesis
Anemia (--> hypovolemia)
Gastric ulcers: etiologies**NSAIDs (esp +steroids) (even from therapeutic doses) (affects blood flow)
**Neoplasia (intra/extra gastric)
Uremia, liver dz, Addisons
DIC, sepsis, portal hypertension
IBD
Stress, exercise
ALMOST ALWAYS 2ry TO DZ
If you find this on histo, how concerned are you?
Helicobacter: found in dogs without vomiting as well as with
Only have to tx when CS of protracted chronic gastritis, & biopsies show organisms in gastric pits
(How to tx helicobacter)(Triple therapy: amoxicillin + metronidazole + bismuth)
Which 2 neoplasias cause ulcers?MCT = histamine release --> H2 recep --> acid secretion
Gastrinoma = gastrin release --> acid secretion (usually in pancreas)
Diagnostics for gastric ulcersBloodwork: CBC, Chem, UA
Rads (abd & thx): perforation --> air in peritneum; mass?
Abd US
+/- endoscopy, surgery
What is happening on this rad?
Perforation from gastric ulcer. Can see outline of diaphragm b/c gas on 1 side in lungs & gas in peritoneum. EMERGENCY SX!!
**How useful is US for ulcers?IF see ulcer: THERE IS ONE! (so, useful for that, e.g. giant mass causing an ulcer). If you dont see it, DOESNT RULE IT OUT! US gets blocked by air, stomach has a lot of air in in (pockets physically block)
**Risks of endoscopy with ulcers?Need to insufflate! So if thin weak gastric wall, could perforate it
Tx of gastric ulcersTreat underlying cause: Misoprostol e.g. added to NSAID & steroid use (PG inhibitor so wear gloves... misscarriage in humans)
Help GI mucosa heal: PPI (proton pump inhibitor) = much better at lowering stomach acidity than H2 blockers (Famotidine)
Analgesia
+/- sucralfate, barium, lidocaine slurry
May need blood transfusions/surgery!
Prognosis of gastic ulcers?Can be fatal :(
Perforation, sepsis, hypoalbuminemia
Necessitates multiple blood transfusions
Underlying neoplasia
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